Ambulatory management of bacteremia and fever in bone marrow transplant patients

Historically, most bone marrow transplant (BMT) recipients at our center who presented with fever or bacteremia were admitted for observation and empiric treatment. With the advent of better outpatient monitoring and once-daily antibiotics, we feel a less restrictive policy should be considered. Treatment in the outpatient department is less expensive than inpatient management and patients prefer home care. To identify factors that are predictive of safe outpatient management, we retrospectively studied consecutive BMT recipients admitted from our ambulatory clinic for fever or bacteremia in the calendar year 1996. We coded which cases could have been handled safely and effectively in the ambulatory setting. Fifty percent (35 of 70) of the admissions for bacteremia and/or fever could have been managed safely in the outpatient department. Multivariable logistic regression models suggest that patients with bacteremia and/or fever who present with gastrointestinal symptoms, or are in the first thirty days after transplantation are significantly less likely to be handled safely as outpatients. Among febrile, pediatric patients, those who are greater than 30 days post-transplant are significantly more likely to be managed safely as outpatients than those who are less than 30 days post-transplant. We have implemented an ambulatory protocol for management of BMT recipients with fever and/or bacteremia that is flexible in its use of hospital admission, but is not a substitute for clinical judgement. This protocol gives criteria for ambulatory management based on a nontoxic appearance, hemodynamic stability, and willingness by the ambulatory physician to observe patients for the necessary duration. A future retrospective study will analyze the effects of this ambulatory-inclusive protocol on morbidity and mortality and will further clarify the indications for ambulatory management presented in this study.