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December 1989, Volume 39, Issue 12

Original Article

PERITONEAL MACROPHAGES TRANSFUSION IN THE TREATMENT OF CHRONIC POSTOPERATIVE WOUND INFECTIONS

Noon S. Dawood Al-Waili  ( Private Clinic, House 34, Street 42, Section 729, Al-Mashtel, New Baghdad, Baghdad, Iraq. )

Abstract

Four patients with chronic post-operative wound infections and wound gapping that failed to respond to antibiotics were treated by allogeneic macrophage transfusions. No harmful effects were observed following macrophage transfusion and the chronic infections were eradicated in the treated patients with complete healing of wounds. Haemoglobin and white cell count were increased after cell transfusion. It could be concluded that allogeneic macrophage transfusion can combat chronic resistant infections and stimulate both wound healing and haemopoiesis (JPMA 39: 310, 1989).

INTRODUCTION

Chronic infections might be the result of failure of antibiotics to eradicate microorganisms. This is partly, due to both the inability of antibiotics to reach effective levels at the site of infections and increasing resistance of bacteria to antibiotic therapy. However, failure of antibiotics may reflect depressed immune functions in the patients. On the other hand, macrophages play a major role in the defence against a variety of infectious agents. Recently, we have found that human peritoneal macrophages, obtained from unrelated donors under-going peritoneal dialysis for recently developed renal failure, could eradicate acute urinary infections which were resistant to an­tibiotic therapy1. Furthermore, it has been found that xenogeneic macrophage transfusions, from human to rabbit2 and from human to guinea pigs (Al-Waili, unpublished observation) could eradi­cate severe or otherwise fatal septicaemia due to infection with E. Colt This new approach for treatment of acute resistant infections by macro­phage transfusion encouraged us to investigate it in the treatment of four patients with chronic resis­tant infections.

PATIENTS AND METHODS

Collection of Macrophages:
Human peritoneal macrophages were col­lected from adult patients undergoing peritoneal dialysis as part of their management of renal failure1-3. Therapeutic high concentration of cells (2-5x 107 cell/ml) were obtained from 5/25 patients undergoing peritoneal dialysis for recently developed renal failure1. The penitoneal washout were centrifuged thrice and washed with normal saline. Differential counts of the cells showed 80-90% macrophages, and the remainder was a collection of lymphocytes and granulocytes.
Patients:
Four patients with chronic post-operative wound infections and gapping were included in the study (Table 1).

The patients had developed wound infections and then gapping during early post-operative periods. Treatment with daily dressing and local and systemic antibiotics were continued for a period of 4-7 months post-opera­tively without healing. At the time of presentation the surgical wounds were found open with pus and yellowish discharges. Wound swabs were collected for culture and sensitivity. Laboratory investiga­tions including WBC, RBC, ESR, Haemoglobin, Blood urea, Blood sugar, Serum creatinine, and liver function tests were performed. The study was fully explained to the patients and informed con­sents were obtained.
Infusion of Macrophages:
Patients were asked to stop taking antibiotics for a period of a week prior to infusion. After this washout period, each patient received a total of 200-250ml of macrophages suspension (1-3 x 107 cells/ml) intravenously (30 drops/minute); and after ten minutes evaluations of temperature, blood pressure and pulse rate were recorded. The patients were discharged 6-10 hours late, and instructed to attend the clinic daily for follow-up (dressing and side effects). Wound swabs were done every day after cell transfusion. Laboratory investigations were repeated weekly.

RESULTS

After cell transfusions wound swabs from the. four patients yielded no growth at 7-10 days. Pus discharge were reduced gradually and stopped within two weeks. Complete closure of wound gappingwere evidentin 1-2monthspost treatment. Haematological investigations (Table II)

revealed elevation of WBC, Hb and lowering of ESR. No changes in blood urea and other investigations were noted. No side effects were recorded during and after macrophages transfusions, apart from mildheadache, rigors and tachycardia. These were overcome using antipyretics. On the other hand, wound swabs from one patient with cholecystec¬tomy still yielded heavy growth of Staphylococcus aureus with mild pus discharge at 3 weeks post-therapy. This patient received another macro¬phage transfusion in similar dosage. At 7 day, wound swabs yielded no growth and complete closure of wound was evident in 1 month.

DISCUSSION

The results confirm the observation that allogeneic macrophage transfusion did not elicit graft-host or host-graft reactions1,4. In addition, repeated macrophage transfusions, obtained from two unrelated individuals and given to one patient, did not initiate adverse reactions. The transfused cells could combat chronic infection and stimulate wound healing and recipient haemopoiesis. In all patients, microorganisms were sensi­tive to some antibiotics but failed to respond to treatment, presumably due to chronic illness or/and defective immunocompetence. Surgical trauma and chronic inflammations caused a progressive defect in immunity and secondary anaemia which resulted probably from over production of prostaglandins from inflamed and damaged tissues5-7.. Moreover, tissue damage and necrosis might hinder antibiotics to reach therapeutic level at the site of infection. The transfused macrophages might enhance immunity of the host against the invading microor­ganisms since they possess immunostimulatory properties. They might represent the bacteria to be recognisedby host T-cells causing T-cell activation induction of killer T-cells, helper T-cells and elaboration of lymphokines. The activation of recipient helper T-cell might potentiate the dif­ferentiation of B-cells into antibody producing plasma cells8,9. On the other hand, the transfused cells might be chemotactically attracted to the infected wounds by some substances including bacteria and bacterial products, antibody antigen complexes, complements and lymphokines9. Cell wall product, lipopolysaccharides, from gram negative bacteria activate peritonealmacrophages to become non-specifically cytotoxic10. Following chemotaxis to the infected wound, the cell might phagocytize the invading bacteria and eliminate infections. However, further studies are needed to substantiate these suggestions. Regarding the effect of macrophages on haemopoietic system, the results show that the recipients, baemoglobin and white blood cells were both increased alter cell transfusions. This means that macrophages might stimulate haemopoiesis. It has been known that macro­phages produce a colony stimulating factor which is essential to form colonies of both granulocytes and monocytes11. Other reports showed that monocytes and macrophages are the main source of colony stimulating factor in man12. In addition, macrophages have been reported to produce erythropotetin, territm, transterrm and they are a source of iron for developing normoblast in the bone marrow13. On the other hand, increased haemoglobin after cell transfusion might be, in part due to elimination of infection. Of great concern is the effect of macrophage transfusion on wound repair. The results show that the post-operative wound gapping and discharging sinuses were completely repaired after cell trans-fusion. When macrophages attracted to the site of the infected area they ingested wound material and acted to debride the wound by releasing proteases, like collagenase. This influenced the rate of collagen degradation14. Macrophages also participate in the wound healing by releasing substances that induce fibroblast proliferation and neovascularization14.

REFERENCES

1. Al-Waili, N.S. and At-Ani, M. Allogeneic transfusion of macrophage in acute urinary tract infections. Clin. Exp. Pharmacot. Physiol., 1986; 13: 132.
2. Al-Waili, N.S., Al-Azzawi, H., Makkiya, M., Fakhri, 0. A note on xenogeneic macrophages transfusion in ex¬perimental septieaemia. J. Appl. Bacteriol., 1984; 57:531.
3. Maddox, Y., Foegh, M., Zeligs, B., Zmudka, M., Bellanti, J. and Ramwell, P. A routine source of human peritoneal macrophages. Scand. J. Immunol., 1984; 19:23.
4. Umer, K, AI-Mondhri, H., Rifaat, U. and Khalil, M. Therapeutic use of peritoneal cells. Lancet, 1976; 1: 1244.
5. Al-Waiti, N., Al-Azzawi, H. Effect of prostaglandin E2 on serum iron after acute and chronic blood loss. Clin. Exp. Pharmacol. Physiol., 1985; 12 : 443.
6. Al-Waili, N., Al-Azzawi, H. and AI-Niaimi, M. Bone marrow cellular elements and peripheral blood indices after haemorrhage and prostaglandin Ez treatment. Saud. Med. J., 1983; 4: 235.
7. At-Waili, N.S., Thewaini, A. and Al-Azzawi, H. Effect of prostagtandin Al. on anti-body production. Wortd con¬ference on Clinical Pharmacology and Therapeutics. New York, Macmillian, 1980, p. 249.
8. Unanue, ES. Cooperation between mononuclear phagocytes and lymphocytes in immunity. N. Engl. J. Med., 1980; 303: 1153..
9. Carre,J.Thebiologyofmacrophages. Clin. Invest. Med.,1980; 1 : 59.
10. Doe, W.F. and Henson, P.M. Macrophage stimulationby bacterial lipopolysaccharides. I. Cytolytic effect of tumour target cells. 3. Exp. Med., 1978 ; 148 : 544.
11. Burgess, A. W. and Metcatf, D. The nature of action of granulocyte-macrophage colony stimulating factors. Blood, 1980; 56: 947.
12. Unanue, E.R. Secretory function of mononuclear phagocytes; a review. Am. J. Pathol., 1976; 83: 396.
13. Rich, I., Kubanek, E. Release of erythropoietin from macrophages mediated by phagocytons of crystalline silica. 3. Reticul. Soc., 1982; 31 : 17.
14. Leibovich, S. 3. and Ross, It The role of macrophage in wound repair; a studywith bydrocortisone and anti-mac¬rophage serum. Am. 3. Pathol., 1975; 78: 71.

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