Once acute GVHD develops, it can be treated with glucocorticoids, antithymocyte globulin, and monoclonal antibodies targeted against T cells or their receptors. GVHD that develops or persists 3 months or more after transplantation is termed chronic GVHD and has features in common with collagen vascular diseases, including a malar rash, sclerodermatous changes, sicca syndrome, arthritis, obliterative bronchiolitis, and, in some cases, bile duct degeneration and cholestasis. In most patients, chronic GVHD eventually resolves and immunosuppressive therapy can be withdrawn, but 1 to 3 years of treatment may be required. Patients with chronic GVHD who are on immunosuppressive therapy are susceptible to bacterial infections and should receive prophylactic antibiotics. During the first 2 to 3 weeks after transplantation, all patients are severely granulocytopenic.
Fever develops in most, and about one third have a positive blood culture.
Febrile granulocytopenic patients should be treated with broad-spectrum antibiotics, and in many centers, antibiotics are initiated once patients become granulocytopenic, to prevent septicemia. The prophylactic administration of fluconazole reduces the incidence of Candida albicans infection. Granulocyte transfusions can be effective in treating specific infections, particularly now that donors can be treated with G-CSF before donation to greatly increase the number of granulocytes that can be collected and transfused. There is no established role, however, for prophylactic granulocyte transfusions. Laminar airflow isolation can reduce the incidence of infection but has no impact on survival in transplant patients treated for malignancy.