Anemia, leukopenia and thrombocytopenia may develop during chemotherapy or radiation therapy. Clinical symptoms and a decrease in the tolerability of radiation therapy usually develop with a hematocrit of less than 30% or hemoglobin of less than 100 g / l, more quickly in patients with coronary or peripheral vascular disease. The appointment of recombinant erythropoietin therapy usually begins with a decrease in hematocrit of less than 32% (Hb <100 g / l). A standard dose of erythropoietin 150–300 U / kg subcutaneously 3 times a week (usually 10 000 IU for adults) is effective and reduces the need for transfusions. The long-acting forms of erythropoietin are also effective and do not require frequent injections (darbopoetin-a at a dose of 2.25–4.5 µg / kg subcutaneously in 1-2 weeks). Sometimes red blood cell transfusions may be needed to eliminate acute cardiorespiratory symptoms.
A decrease in platelet count of less than 10,000 / μL, especially with bleeding manifestations, requires a platelet concentrate transfusion. The efficacy of thrombopoietin and small molecules with thrombopoietin activity is being studied.
Leukocyte depletion from transfused blood components prevents alloimmunization and should be used in patients undergoing multiple courses of chemotherapy and candidates for stem cell transplantation. In addition, leukocyte depletion reduces the likelihood of cytomegalovirus transmission to the patient through donor's leukocytes. Gamma-irradiation of blood products inactivates lymphocytes, prevents graft versus host transfusion disease, and is also indicated for patients undergoing severe immuno-suppressive chemotherapy.
Neutropenia is usually defined as a decrease in the absolute number of neutrophils less than 500 / μl, is a predisposing factor to the development of life-threatening infections. Patients with a lack of febrile fever require close monitoring and should be instructed in the need to avoid contact with sick people or crowded places (shops, train stations, airports). Although the majority of patients do not need antibiotic therapy, for patients with leukopenia and severe immunosuppression (after T-cell depletion or in violation of their function), trimethoprim — sulfamethoxazole (one tablet per day) is prescribed, as a preventive measure for Pneumocystis jiroveci (former P. carinii ).In patients after transplantation or who received high-dose chemotherapy, it is necessary to consider the purpose of antiviral prophylaxis (acylcyclo-vir 800 mg orally 2 times a day or 400 mg intravenously via h) in the presence of positive serological tests for the herpes simplex virus.
A fever greater than 38 ° C is critical in patients with neutropenia. The examination should include immediate chest radiography, microbiological examination of blood, urine, stool and any suspicious skin lesions. The examination also includes the places of possible abscess formation (skin, ears); skin and mucous membranes for the presence of herpetic lesions; the presence of lesions of the retinal vessels, suggesting metastasis of the infectious process; catheterization sites. Examination of the rectum and rectal thermometry should, if possible, be avoided in neutropenic patients due to the risk of bacteremia.
Patients with neutropenia and febrile fever should receive broad-spectrum antibiotics selected based on the most likely source of infection.A typical regimen includes cefepime 2 g intravenously after 8 hours or ceftazidime 2 g intravenously every 8 hours immediately after taking the material for microbiological studies. In the presence of diffuse infiltrates in the lungs, it is necessary to examine the sputum on P. jiroveci and, with a positive result, it is necessary to prescribe the appropriate therapy. If the fever is resolved within 72 hours after the start of empirical antibiotic therapy, treatment should be continued until the absolute number of neutrophils is increased to more than 500 / μl. If the fever persists for 0 hours, it is necessary to add antifungal agents due to the possible presence of a fungal infection. At the same time, it is necessary to conduct repeated examinations to find a hidden source of infection (CT scan of the chest and abdominal organs).
In patients with neutropenia associated with chemotherapy, especially after high-dose chemotherapy, a granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) can be assigned to shorten the period of leukopenia. The use of G-CSF 5 μg / kg subcutaneously once a day until days or a prolonged form (pegfilgrastim 6 mg subcutaneously once per course of chemotherapy) accelerates recovery of leukocyte count.These drugs are not prescribed in the first 24 hours after chemotherapy, and for peg-filgrastim - a minimum of days must pass before the start of the next course of chemotherapy. These drugs are prescribed immediately with fever or sepsis or in afebrile patients with a neutrophil level below 500 μg / ml.
Outpatient treatment is used at many centers.cytopeniaselected low-risk patients with fever and neutro-singing. Candidates should not have a hypothesis, mental status disorder, respiratory distress, uncontrolled pain, serious comorbidities such as diabetes, heart disease, or hypercalcemia. In such cases, the daily monitoring of the doctor, the visits of the nurse and the home administration of antibiotics are necessary. Some regimens include oral antibiotics, such as ciprofloxacin 750 mg 2 times a day plus amoxicillin / clavulanate 875 mg orally 2 times a day or 500 mg 3 times a day. In the absence of adopted programs for the management and treatment of fever in neutropenic patients on an outpatient basis, hospitalization is necessary.