From the Guidelines
Typhoid fever typically presents with a characteristic stepwise fever pattern, where the fever begins as low-grade and gradually increases over the first week of illness, reaching 103-104°F (39-40°C) by the end of the week. The fever pattern in typhoid is often described as "step-ladder" because the temperature rises a bit each day and falls slightly each morning, but with an overall upward trend 1. During the second week, the fever remains persistently high (plateau phase), and if untreated, may continue for 3-4 weeks before gradually subsiding. This distinctive fever pattern occurs because Salmonella Typhi bacteria multiply in the bloodstream during the first week, triggering a progressive inflammatory response. As the infection localizes in intestinal lymphoid tissue and other organs, the fever stabilizes at a high level. The pattern may be altered by early antibiotic treatment, with modern therapy typically resolving fever within 3-5 days of starting appropriate antibiotics such as ceftriaxone, azithromycin, or fluoroquinolones 1. Notably, this classic pattern may not be observed in all patients, particularly in children, the elderly, or those who have received partial antibiotic treatment. Some key points to consider in the diagnosis and management of typhoid fever include:
- Blood cultures have the highest yield within a week of symptoms onset 1
- Stool and urine cultures become positive after the first week 1
- The sensitivity for blood cultures is reported as 40-80% 1
- The use of ciprofloxacin discs to determine Salmonella typhi and Salmonella paratyphi sensitivity is unreliable 1
- Newer rapid serological tests detecting IgM against specific antigens have been developed, but so far have shown mixed results 1
From the Research
Fever Pattern in Typhoid
- The fever pattern in typhoid can vary depending on the treatment used.
- According to a study 2, defervescence occurred in half the patients in both the ceftriaxone and chloramphenicol groups during the first 7 days, but on days 9 to 13 after the start of treatment, nine patients in the ceftriaxone group, compared with six patients in the chloramphenicol group, remained febrile.
- Another study 3 found that the mean duration of fever was four days in the ciprofloxacin group and about five days in the ceftriaxone group.
- A study 4 reported that fever subsided in most patients between six and eight days, with three patients having a prolonged and moderate fever for 11 days in the ceftriaxone groups.
- A review of clinical trials 5 noted that ideal treatment should cause defervescence within 1 week, and azithromycin was found to meet this criterion better than other drugs.
Treatment Comparison
- The effectiveness of different treatments on fever pattern can be compared:
- Ceftriaxone versus fluoroquinolones: time to defervescence may be longer with ceftriaxone 6.
- Ceftriaxone versus azithromycin: time to defervescence may be shorter with ceftriaxone 6.
- The choice of treatment should take into account current, local resistance patterns and the route of administration 6.