Prophylaxis of infection in patients with aplastic anemia receiving allogeneic marrow transplants

One hundred one patients with severe aplastic anemia underwent allogeneic marrow transplantation and received one of three forms of infection prophylaxis: oral nonabsorbable antibiotics and isolation and decontamination in a laminar airflow room (36 patients); prophylactic granulocyte transfusions from a single family member donor (33 patients); or conventional treatment in single rooms with hand-washing and mask precautions (31 patients). During the period of granulocytopenia, patients in the laminar airflow rooms acquired fewer infections than either of the other groups, but this difference was statistically significant only when compared with the group receiving conventional treatment. Patients in the laminar airflow rooms had significantly fewer infections after engraftment as compared with the other two groups. Incidence of interstitial pneumonia and graft rejection was not different among the three groups. Acute graft-versus-host disease occurred later (Day 47) in the group in the laminar airflow rooms as compared with the group receiving prophylactic granulocyte transfusions (Day 23) or the group receiving conventional treatment (Day 20). The incidence of grades II to IV acute graft-versus-host disease was less in the patients in the laminar airflow rooms but only reached borderline significance (p = 0.08) when compared with the conventionally treated patients. The survival at Day 100 was 92 percent for the group in the laminar airflow rooms, 79 percent for the group receiving prophylactic granulocyte transfusions, and 64 percent for the group receiving conventional treatment.

Symposium on infectious complications of neoplastic disease (Part II). Granulocyte transfusions

Laboratory and clinical studies have demonstrated beyond question that granulocyte transfusions can have a beneficial effect on the incidence and course of bacterial infection. The increment of improved survival produced by granulocyte transfusions depends on the effectiveness of the alternative (primarily antibiotic) therapy alone, and this varies with the pattern of bacterial predominance and sensitivity, which is notoriously changeable. The absolute effectiveness of granulocyte transfusion therapy is influenced by the quality of the transfusions and the immune status of both the recipient and the granulocyte donor. The indiscriminate transfusion of inadequate quantities of granulocytes from random donors into sensitized recipients should be discouraged. Severely neutropenic patients with established infection unresponsive to antibiotic therapy are appropriate recipients of granulocyte transfusions. Well-designed programs of prophylactic granulocyte transfusions can reduce the occurrence of bacterial infection in neutropenic patients, but there are few clinical situations in which their use is justified. The use of cytomegalovirus-seropositive granulocyte donors for cytomegalovirus-seronegative recipients should be avoided. There is a need for technical advances that will increase the ease and efficiency of granulocyte procurement.

Granulocyte transfusion therapy

Granulocyte transfusion therapy has been used as an adjunct to broad spectrum antibiotics in the management of serious infections in granulocytopenic patients. This treatment is based upon the observation that the incidence of infection is inversely related to the absolute granulocyte count in granulocytopenic patients and upon the demonstrated value of replacement therapy of other blood cell components such as platelets for thrombocytopenia. In addition, the occurrence of dramatic clinical improvement frequently noted with only small increases in granulocyte count as the marrow begins to regenerate suggests that transfusions of granulocytes should be of benefit.

Controlled study of therapeutic granulocyte transfusions in granulocytopenic patients with severe infections

The effectiveness of therapeutic granulocyte transfusions was studied in a controlled trial involving 75 granulocytopenic patients with severe infections. Patients who had granulocyte counts of less than 200/mm3 and no response to antibiotic therapy were assigned to receive antibiotic therapy alone or granulocyte transfusions plus antibiotic therapy. Granulocytes were collected by filtration leukapheresis (FL), intermittent flow centrifuge leukapheresis (IFCL) or continuous flow centrifuge leukapheresis (CFCL). Therapeutic effects of granulocyte transfusions were evaluated on the basis of 20-day survival after entry into the study. The patients were divided into three groups: 1) 22 patients received antibiotic therapy alone for 29 infectious episodes (control group); 2) 27 patients received 131 transfusions of granulocytes collected by FL for 31 infectious episodes (FL group); 3) 26 patients received 139 transfusions of granulocytes collected by IFCL and CFCL for 27 infectious episodes (IFCL & CFCL group). The overall survival of the transfused patients was not significantly different from that of the untransfused patients. Similarly, there was no significant difference in survival between the transfused and untransfused patients when the data concerning septicemia were analyzed. When patients showed bone-marrow recovery, which was indicated by recovery of granulocytes to 500/mm3 or more during the study, 20-day survival was observed in 13 of 14 untransfused patients and in all of 26 transfused patients. In contrast, the survival rate for the patients without bone-marrow recovery was 13% (2/15) in the control group, 39% (7/18) in the FL group and 57% (8/14) in the IFCL & CFCL group respectively. Thus, the survival rate was significantly higher for the transfused than for the untransfused patients. These observations suggest that therapeutic granulocyte transfusions may be of limited value in improving the outcome of severe infections in persistently granulocytopenic patients. Since bone-marrow recovery is a critical factor for the prognosis of severe infections, therapeutic granulocyte transfusions do not provide any beneficial effects in granulocytopenic patients whose bone-marrow function will recover.

Pulmonary complications in patients receiving granulocyte transfusions and amphotericin B

To evaluate the possibility that in febrile granulocytopenic patients amphotericin B given along with granulocyte transfusions could increase the incidence of pulmonary complications, we studied 43 severely granulocytopenic patients during 46 episodes of fever. Granulocytes were administered as part of the clinical protocol to all 19 patients who had clinically or microbiologically documented infection; the other 24 patients were randomly allocated to treatment with granulocytes (13 patients) or without granulocytes (11 patients). In all, 32 patients received granulocyte transfusions during 35 episodes of fever. Pulmonary complications developed in six patients in each of the two randomized groups. The incidence of pulmonary complications was not influenced by the number of granulocyte transfusions or by the number of granulocytes per transfusion. Pulmonary complications were significantly more likely to occur in patients with fungal infections. Amphotericin B was given according to clinical indications; 21 patients in all received it. Survival was significantly poorer in patients with pulmonary complications, but the administration of amphotericin B was not related either to survival or to the incidence of pulmonary complications. We conclude that pulmonary complications and poor prognosis are related to underlying pulmonary fungal infection and not to any interaction between amphotericin B and granulocyte transfusions.

Health risks to cytapheresis donors

Platelets and granulocytes collected by cytapheresis techniques are recognized as drugs by the US Food and Drug Administration. Though potentially life-saving, like all drugs or therapeutic modalities they have many side-effects, and untoward reactions occur in recipients. However, unlike any other class of drug, cytapheresis products cause untoward and occasionally serious reactions in humans during their preparation. Since the only source for these medications is healthy, human blood donors we should be doubly certain that we use them with care and for very specific indications. Primum non nocere--first, do no harm--is an old and valuable medical axiom , and it applies to our blood donors as well as to our patients. Careful review of our use of these products and intelligent monitoring of appropriate medical and laboratory data in our donors are absolute necessities that we owe to our patients and our various publics . To do less reduces medical practice to mere technology, a state of affairs already too commonplace.

[Substitution of blood components]

Cell substitution in the form of "tailored haemotherapy " should be an essential part of medical oncology at the present time. In the conventional therapy of solid tumors patients do not enter into prolonged phases of severe haemopoietic insufficiency. Accordingly platelet and granulocyte transfusions will be exceptional. It is mainly the red cell transfusion which plays the most important role. The possible complication of cell substitution should always be kept in mind. Here the risk of alloimmunisation which makes a continuation of transfusion therapy or a subsequent bone marrow transplantation problematic, is just one of the examples. Modern cell separation techniques allow the production of highly concentrated cell preparations aiming at the reduction of the frequency of transfusions and minimizing the risk of sensitisation. If rich concentrated preparations have to be given to immunodeficient patients an irradiation should proceed their transfusion, otherwise the immunocompetent lymphocytes contained in the preparations could induce graft versus host reactions. Allogenic bone marrow transplantation is more becoming the treatment of choice for severe combined immunodeficiency, severe aplastic anemia, acute myeloid leukemia, and chronic myeloid leukemia. At the present time the place of allogeneic or autologous bone marrow transplantation as a treatment of lymphomas and solid tumors is still unsettled.

Role of the blood bank in bone marrow transplantation

The wide variety of special blood components, special procedures, increased red blood cell serologic testing, the complexity of ABO and Rh type changes, difficulty in selecting the correct ABO and Rh type of component, and necessity to irradiate all blood and components for these patients present a challenge to the internal operation of the blood bank. Although the blood transfusion supportive care required by bone marrow transplant patients is complex, it also opens many new and exciting possibilities for blood bank activities, and presents many opportunities to better understand the basic nature and clinical relevance of blood groups.

Granulocyte collection by continuous-flow centrifugation using arteriovenous shunts

Two thousand nine hundred twenty-seven granulocyte collections were made using continuous-flow centrifugation with the Aminco Celltrifuge I, the Fenwal Celltrifuge II, and the IBM 2997. There were 231 recipients and 246 donors. In 32 patients attempts to provide daily granulocyte transfusions from a single donor were unsuccessful owing to clotting of the silastic-Teflon arteriovenous shunt. Repeated granulocyte donations produced severe anemia requiring red cell transfusions in all the females and most of the males who had previously donated marrow for transplantation. Granulocyte collections were similar when collected with the Celltrifuge I or the IBM 2997, but collections with the Celltrifuge II were smaller. Infusion of hydroxyethyl starch directly into whole blood as it entered the centrifuge increased granulocyte collections. Granulocyte collections decreased with increasing number of daily collections.

Development of Aspergillus sinusitis in a patient receiving amphotericin B. Treatment with granulocyte transfusions

Fulminant Aspergillus sinusitis is a disease of immunocompromised hosts strongly associated with neutropenia. A case of sinusitis due to Aspergillus flavus that developed in a patient with acute leukemia during the third week of treatment with amphotericin B is described. Indium 111-labeled white blood cell scanning demonstrated uptake of granulocytes into the involved sinuses. Thereafter, use of granulocyte transfusions was associated with stabilization of the patient's clinical course.

Putative methods for prevention and treatment of neonatal septicemia

The high mortality rate observed in newborn infants who contract bacterial sepsis within the first day of life has prompted investigators to seek new methods for the prevention and treatment of this disorder. Among the putative measures recommended for prevention are: administration of antimicrobials to all infants at the time of delivery, identification and treatment of pregnant women colonized with those bacteria known to be major neonatal pathogens and immunization of women to major neonatal pathogens. Three other measures, targeted at diminishing the mortality and morbidity in those in whom preventive measures fail, include: granulocyte transfusion, exchange transfusion and administration of antibody.

Donor reaction to hydroxyethyl starch during granulocytapheresis

Granulocyte transfusion therapy has become relatively routine in centers treating patients with hematologic malignancies. The yield of granulocytes has been improved with newer leukapheresis techniques, premedication with corticosteroids, and the use of sedimenting agents, usually hydroxyethyl starch. Despite the relative safety of these techniques, there are risks to participating donors. A case of a donor reaction related to hydroxyethyl starch is presented. This report is a reminder that leukapheresis must be performed with careful consideration of therapeutic benefit-to-risk ratios.

Recent advances in management of bacterial meningitis in neonates

The current incidence of neonatal sepsis in the United States varies from less than 1 to 8.1 per 1000 live births. The incidence of bacterial meningitis is about one-third of the number of infants with sepsis. The mortality is 20 to 30% and many survivors are severely impaired. Group B streptococcus and Escherichia coli are the most frequent causes of meningitis. Because of the difficulty of clinical diagnosis, many infants receive presumptive therapy for suspected sepsis or meningitis although few have documented infection. Between 5 and 10% of newborn infants born in the United States receive antimicrobial agents in the nursery, usually a penicillin and an aminoglycoside. To lower the continued high mortality and morbidity of meningitis due to gram-negative enteric bacilli, collaborative randomized trials evaluated the efficacy of gentamicin administered via the intrathecal route, gentamicin administered into the ventricle and most recently, the efficacy of moxalactam. Neither intrathecal or intraventricular drug, both in combination with parenteral drug, was advantageous when compared with parenterally administered drug alone. The mortality rate and number of days of culture positive cerebrospinal fluid were similar in infants who received moxalactam and ampicillin and infants who received amikacin and ampicillin. Adjunctive therapies including granulocyte transfusion, administration of hyperimmune gamma globulin and exchange transfusion are now under investigation. Initial studies of prevention of systemic bacterial infection by prophylactic ampicillin administered to the mother at delivery and use of group B streptococcal vaccine administered to susceptible women in the child bearing age show promise.

[Amodiaquine-induced agranulocytosis in malaria prevention: demonstration of an amodiaquine-induced cytotoxic antibody against granulocytes]

A patient is presented who developed agranulocytosis while taking amodiaquine for suppressive therapy of malaria. An amodiaquine-dependent granulocytotoxic antibody could be demonstrated in the patient's serum on day 1 after stopping amodiaquine medication. Granulocyte transfusion was ineffective on days 6 and 7, possibly due to the slow elimination of the drug.

Quantitative fecal indium 111-labeled leukocyte excretion in the assessment of disease in Crohn's disease

The assessment of disease activity in Crohn's disease involves determination of either clinical indexes (e.g., Crohn's disease activity index) or laboratory measurements (e.g., C-reactive protein and erythrocyte sedimentation rate). These have the disadvantage of being indirect and nonspecific correlates of gut inflammation. We have assessed disease activity in Crohn's disease by measurement of fecal leukocyte excretion after intravenous administration of either 111In-labeled mixed leukocyte or pure granulocyte preparations. With mixed leukocyte preparations, fecal excretion of radioactivity correlated with Crohn's disease activity index (r = 0.78, p less than 0.001) and C-reactive protein (r = 0.74, p less than 0.01). Using pure granulocytes, fecal 111In excretion (range 1.5%-52%) was much higher than with mixed leukocytes (range 0.1%-11.0%), showing significant correlations with Crohn's disease activity index (r = 0.731, p less than 0.001), C-reactive protein (r = 0.716, p less than 0.001), and erythrocyte sedimentation rate (r = 0.676, p less than 0.001). Quantitative fecal excretion of 111In-leukocytes is a new method of assessing disease activity in Crohn's disease, specific for bowel inflammation and suitable for objective assessment of disease activity in therapeutic trials.

Current status of leukocyte and platelet administration in cancer therapy

Leukapheresis and plateletpheresis are rather commonly performed in order to obtain single donor concentrates of granulocytes and platelets. These procedures, although relatively safe, present occasional risks to donors and recipients. Some of the occasional adverse problems experienced by donors include citrate toxicity or acute hypocalcemia, hypotension, hypervolemia, venospasm or vein occlusion, chills, anaphylactoid reactions, hemorrhage, abdominal pain or complications related to equipment failure and related technical problems. Potential risks to donors include those related to the receiving of six percent hydroxyethyl starch (HES), dextrans, or corticosteroids, lymphocyte depletion or immunosuppression, and effects on the complement system. Prophylactic granulocyte transfusions to prevent the occurrence of infections and associated complications in neutropenic patients have not proven to be efficacious; therapeutic granulocyte transfusions appear to be more effective. Indications for therapeutic granulocyte transfusions include those patients with known infections unresponsive to appropriately aggressive antibiotic chemotherapy over a two or three day period combined with findings of a peripheral granulocyte count less than 500 mm3 and especially those with counts below 100 mm3 and/or prolonged fever greater then 38 degrees C (100.4 degrees F) for 24 to 48 hours. In addition, the patient should have a reasonable chance for bone marrow recovery. Hazards or complications associated with granulocyte transfusions include: (a) immediate transfusion reactions, (b) hypersensitivity reactions, (c) pulmonary infiltrates, (d) alloimmunization, (e) transmission of infections, and (f) the possibility of Graft vs. Host (GVH) disease. The current best use of apheresis platelets is to provide therapeutic doses of single donor matched platelets for patients refractory to pooled random donor platelets. Alloimmunization represents the major complication of therapeutic platelet transfusion and is characterized clinically by the failure to achieve expected platelet count increments after transfusion. Future developments which might greatly improve the effectiveness of therapeutic and possibly prophylactic leukapheresis and plateletpheresis include the development of effective sedimenting agents with shorter biological half-lives, more efficient and less expensive methods of procurement of granulocytes and platelets, improved methods of cryopreservation of granulocytes and platelets, better methods for detecting and quantitating antigranulocyte and/or antiplatelet antibodies, and more efficient evaluation of possible synergism of granulocyte transfusions with antibiotic therapy and residual host defense. These improvements may be of great value in the effective utilization of granulocyte and platelet products and in determining which patients are most likely to receive the maximum benefit from granulocyte and platelet support.

Prolonged cryopreservation of human granulocytes

Normal human granulocytes prepared by dextran sedimentation were cryopreserved in 10 percent dimethyl sulfoxide and 25 percent autologous plasma using controlled-rate freezing at -1 degrees C per minute. Twenty-four samples were stored from 0 to 8 months in the vapor or liquid phase of liquid nitrogen. The mean cell recovery was 58 +/- 4 percent and the mean bactericidal activity using Staphylococcus aureus was 72 +/- 4 percent. Cells stored for approximately 5 months examined with transmission electron microscopy had intact cell membranes and granules although some nuclear changes were observed. No decline in cell recovery or bactericidal activity was observed with prolonged storage and there was no advantage of liquid over vapor phase. Samples stored for over 8 months showed a 73 percent cell recovery and a 77 percent bactericidal activity. Maintenance of granulocyte function after prolonged cryopreservation in these studies suggests the feasibility of cryopreserved granulocyte transfusion therapy.

Invasive aspergillosis

Invasive fungal disease of humans caused by species of the genus Aspergillus Micheli ex Linnaeus has become a significant and prevalent problem in contemporary medicine, particularly with regard to the compromised host. This review addresses the current status of invasive aspergillosis, including microbiological, clinical, and pathologic aspects. Diagnostic and therapeutic considerations are discussed with a view toward early and aggressive intervention in order to prevent the high mortality rate associated with aspergillosis.

Normal bone marrow as a source of granulocytes for transfusion

A method for obtaining granulocytes for transfusion by direct aspiration of bone marrow from normal donors is described. The bone marrow is the major storage reserve for granulocytes with as many as 60 times more granulocytes than in the peripheral blood. With current methods of leukapheresis from peripheral blood, steroids, hydroxyethyl starch, and anticoagulants are given to the donor and his processed blood is returned. Bone marrow aspiration spares the donor such treatment. In addition, no costly machine is necessary and the whole procedure takes less than 2 hours. Due to minimum manipulation, cell viability is not impaired. Furthermore, some committed granulocyte stem cells, as well as nonmature granulocytes, are transfused. These cells have the potential to mature to efficient phagocytes in the patient's circulation.