Supportive care

Intensive supportive care is essential if the treatment of acute leukaemia is to be successful. Types include:

• treatment and prophylaxis of infectious diseases
• fungal infections
  • are common in patients with prolonged neutropenia following cytotoxic therapy
  • fungal infections carry a high mortality (1)
  • systemic fungal infection should be suspected if the neutropenic patient remains febrile despite intensive antibiotics and should be administered empiric antifungal therapy
  • oral fluconazole or non-absorbable amphotericin may prevent topical infection
  • prophylaxis is with a drug with antimold activity e.g. - itraconazole, posaconazole, or amphotericin (2)
• bacterial infections
  • empiric broad-spectrum antibiotics - an absolute necessity for febrile neutropenic patients
    • meta analysis have shown that beta-lactam antibiotic monotherapy is better than the combination of a beta-lactam and an aminoglycoside (1)
  • antibiotic prophylaxis should be given after chemotherapy for AML with a preference for a quinolone (2)
• viral infections
  • particularly of the herpes group are common
  • cytomegalovirus is a hazard in bone marrow transplantation and patients at risk should be given screened CMV-negative blood products.
  • pneumocystis pneumonia is risk during ALL maintenance therapy and should be prevented by low-dose co-trimoxazole.
• special attention should be given to measures which prevent infections such as
  • personal hygiene and dental care
  • hand washing and decontamination before contact with the patient for all healthcare personnel and visitors
  • removal of flowers and plants which could be a potential source of fungal spores and Pseudomonas (1)
• growth factor
• there is no survival benefit from the use of growth factors following AML chemotherapy but growth factor use does reduce the duration of neutropenia, of antibiotic use and of hospital stay (1)
• the routine use of growth factor therapy in AML is not recommended
• transfusion therapy (2)
• platelet transfusion
  • American Society of Clinical Oncology guidelines recommend a threshold of 10 × 109/L for prophylactic platelet transfusions
  • in addition, risk factors such as mucosal bleeding, infection, severe mucositis and fever should be assessed as well and transfusion threshold should be increased
  • leucodepleted platelet transfusions are routinely used in UK to reduce the risk of alloimmunisation and a poor response to platelet trasfusion
  • tranexamic acid may be used to reduce bleeding and platelet transfusion (1)
• red cell transfusion
  • there is lack of evidence in support of red cell transfusion but it is generally accepted to keep the hemoglobin level above 8 g/dL, especially in thrombocytopenic patients (2)
• granuocyte transfusion
  • there is no good evidence to recommend granulocyte transfusions in treatment of AML

Reference:

• (1) British Committee for Standards in Haematology et al.Guidelines on the management of acute myeloid leukaemia in adults. Br J Haematol. 2006;135(4):450-74.
• (2) Döhner H et al. Diagnosis and management of acute myeloid leukemia in adults: recommendations from an international expert panel, on behalf of the European LeukemiaNet. Blood. 2010;115(3):453-74.