Birgitta Versluijs

44 Patients and methods Supportive care and graft-versus-host disease prophylaxis All patients received antiemetic drugs. Prophylactic anticonvulsive therapy (clonazepam) was given to those patients receiving busulfan. Antibiotic prophylaxis involved daily ci- profloxacillin and fluconazole from the start of conditioning until the resolution of neu- tropenia (3 days of >500,000 neutrophils/mL). Additional prophylaxis against Strepto- coccus viridans in the mucositis phase was given with cefazoline. Starting 1 month after transplantation, cotrimoxazole 3 times a week was given as Pneumocystis carinii pneu- monia prophylaxis. Only in cases of positive serology for herpes simplex virus was prop- hylaxis (with acyclovir) administered. No prophylaxis for other viruses was given. IgG levels were checked every 2 weeks; intravenous immunoglobulin was given only to those patients with an IgG level <4 g/L. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine (aiming for a trough level of 100-250 mg/L, based on national protocol guidelines), supplemented with methylprednisolone (MP; 1 mg/kg/day for 28 days) in patients receiving a cord blood (CB) transplant, or methotrexate (short course, 10 mg/m 2 on days 1, 3, and 6) in patients receiving an unrelated bone marrow (BM) or peripheral blood stem cell (PBSC) transplant. In patients receiving an unrelated donor graft (CB, BM, or PBSC), antithymo- cyte globulin (ATG) serotherapy was administered until day –1, with ATG-fresenius for patients with acute lymphoblastic leukemia and thymoglobulin for all other indications. Infection monitoring Bacterial, fungal To monitor bacterial colonization, nose/throat swabs and stools were cultured weekly and processed in accordance with standard microbiological procedures. Up to June 2006, we tested for galactomannan (Platelia Aspergillus enzyme immunoassay; Bio-Rad, Hercules, CA) in cases of suspected Aspergillus infection, based on such clinical symptoms as pro- longed fever during systemic broad antibiotic therapy and radiologic findings. After June 2006, we routinely monitored galactomannan twice weekly. Viral Plasma was tested weekly for Epstein-Barr virus (EBV), cytomegalovirus (CMV), hu- man herpes 6 virus (HHV6), and adenovirus DNA positivity by real-time polymerase chain reaction (PCR) (see next section). In patients deemed positive (viral load >400 cp/ mL), this test was done twice a week. Adenovirus (viral load >1000 cp/mL) was treated preemptively with cidofovir. CMV (viral load .1000 cp/mL) was treated preemptively with foscavir or ganciclovir. Depending on the viral load, the immunosuppressive regimen, and signs of posttransplantation lymphoproliferative disease, EBV was treated preempti- vely with anti-CD20 (rituximab). 3