Neutropenia (Low Neutrophil Count)

Neutropenia is a low white blood cell count. Neutrophils are one type of white blood cell. White blood cells help the body fight infection. People with neutropenia have a low number of these white blood cells, so it is harder for their bodies to fight infection. Neutropenia can be caused by chemotherapy and radiation treatments to areas of the body that produce blood cells. In addition, some cancers may cause a decrease in the body’s ability to form normal new neutrophils.

When you have a low neutrophil count, it is very important to protect yourself against infection. During this time of low neutrophil counts we will instruct you to follow neutropenic precautions to protect yourself against infection. You also must call your doctor as soon as you feel you may be getting an infection.

Neutropenic Precautions: Ways to avoid infection

Hand washing

Hand washing is the best way to stop the spread of infections. The hands can have many germs on them that can cause an infection. Patients with low neutrophil counts can get an infection more easily. Germs on the hands can get into the mouth or nose easily. Washing your hands with a liquid anti-bacterial soap and water can help prevent infection.

People who will be coming into contact with you should wash their hands often.

Hand washing should be done:

Before eating, drinking, and taking medicine
After using the bathroom
Before touching food
Before and after any type of physical care ( ex: mouth care.)
Before and after touching the eyes, nose, or mouth
After touching things that may be dirty
After contact with pets

Wash your hands this way:

Wet hands under a stream of warm water.
Using liquid anti-bacterial soap, scrub for at least 15 to 30 seconds.
Scrub under your nails daily and whenever they become dirty.
Rinse well under a stream of warm water.
Use a paper towel to turn off the faucet.
Dry your hands thoroughly.

Keep anti-bacterial wipes in your car, purse, or pocket for times when soap and water may not be available.

Visitors

Stay away from people who are coughing, sneezing, or sniffling. People with colds, flu, or other contagious diseases should not visit you.

You should avoid babies, children, or adults who have had certain live vaccinations. Avoid contact with people who have had a chicken pox vaccine for 6 weeks and the smallpox vaccine for 3 to 4 weeks (until a scab falls off from their injection site.) Avoid people who have had the intra-nasal flu vaccine for 7 days. Questions about other vaccinations should be discussed with your doctor.

Tell your doctor or nurse if you have been in contact with anyone having a contagious disease or with someone who has recently been vaccinated with a live vaccine.

Crowds

Until your white blood cell count goes back to normal, you should be aware of how many people are near you. Think of a crowd as more than 8 people in an average sized room (living room or family room). If you are out and strangers are within 3 feet of you, you are in a crowd. Make sure you can step back or walk away if there are strangers around you.

When your white blood cell count is very low, carry a few masks with you so that you can wear one if you must be in a crowded area. You should wear a mask when you are in a crowd because you don’t know who may have an infection. You do not need to wear a mask outdoors. A family member or housemate who has a cold or infection should wear a mask in your home.

There are public places you can visit. You can go to these places when fewer people are likely to be there. This is usually mid-morning or mid-afternoon on weekdays. Avoid weekend visits to public places or when they are crowded.

Examples of places you can go:

Places of worship (sit in the first or last pew or an uncrowded section)
Museums
Shopping mall
Grocery store
Parks and playgrounds
Weekday afternoon movies

Definitely avoid:

Crowded theaters
Concerts
Bars
Crowded stores
Aviary and pet stores
Greenhouses, floral shops, conservatories
Swimming pools

Safe food preparation and storage

Wash hands, utensils, counters, and tables with hot soapy water before and after preparing food.
Don’t use sponges or wooden cutting boards. These have germs on them that can get onto food.
Keep all raw meat and seafood away from ready-to-eat foods. It’s a good idea to put them in a sealed plastic bag in the refrigerator or freezer.
Always defrost food in the refrigerator.
Always cook food to the proper internal temperature.
When reheating, bring liquids to a boil.
Refrigerate or freeze leftovers within 2 hours. Do not use leftovers that have been in the refrigerator for more than 2 days.
Do not eat from other people’s plates, utensils, or glasses.

Preventive Care

There are ways to help reduce the risk of infection.

Mouth

Good mouth care is very important. Dryness, soreness, or slight burning may be signs of mouth problems. It is important to examine your mouth every day so that you can see changes as early as possible. Use a mirror and flashlight to examine your lips, gums, tongue, the inside of your cheeks, and the roof of your mouth. Look for blisters, red areas, ulcers, white patches or coating, or bleeding. Report any of these changes to your nurse or doctor as soon as possible.
Use a very soft toothbrush.
Brush your teeth gently but thoroughly with a soft bristle toothbrush within 30 minutes after meals and before bed.
Keep your toothbrush clean. Rinse with warm water and store in a clean, dry, well-ventilated area.
After brushing your teeth, rinse your mouth for 1 to 2 minutes with a mixture of a half-teaspoon of salt in 8 ounces of water or a half-teaspoon of baking soda (sodium bicarbonate) in 8 ounces of water.
Do not use mouthwash that contains alcohol. Alcohol is irritating and drying to the mouth.
Gently floss your teeth once each day unless you have been told not to. Do not floss if it causes pain or bleeding.
If you wear dentures, clean your dentures every day. Brush them and then soak them in an effervescent denture cleaner for a few minutes. Rinse them well. Use fresh soaking solution every time you soak them. Try not to wear dentures that do not fit, they can irritate the gums. If necessary, contact your dentist to have your dentures fitted properly.
Keep your lips moist. Use a water-soluble lubricant such as Surgilube or K-Y Jelly.
Check with your doctor or nurse before having any dental work done. Also, tell your dentist about your neutropenia before your appointment.

Skin

Be careful to avoid cuts and scratches. Keep your skin clean to keep germs from entering your body. If you see any changes, such as redness, swelling, cuts, sores, drainage, or rash, or if you have pain or tenderness, tell your nurse or doctor.

Keep your skin healthy by doing the following:

Shower or bathe daily using mild soap. Do not use bubble bath or perfumed soaps.
Use a mild lotion for dry skin. Do not use perfumed lotions.
Clean any cut or scrapes with soap and warm water.
Wear shoes or slippers when walking.
Wash hands before eating, before and after preparing food, and after going to the bathroom.
Wear gloves when washing dishes.
File nails instead of cutting and avoid making nails too short. Soften cuticles with lotion.
Avoid nail salons and “fake” fingernails, wraps, and tips.
Tell your doctor about any redness or swelling around the nails.
Use an electric razor when shaving.
Do not squeeze blemishes.
Avoid gardening and mowing the lawn.
Avoid using sharp objects.
If you have a central venous catheter, before showering you must tape waterproof material such as household plastic wrap to cover the dressing and injection cap.

Lungs

It is important to know the early signs of lung infection and report them to your doctor or nurse immediately. Signs of lung infection include shortness of breath, new cough, coughing up mucus, and chest or back pain.

You must avoid all of the following:

Crowds
Dusty and stuffy areas, such as attics and basements
Smoking and places with cigarette smoke
Close contact with sick people
Grooming pets or cleaning bird cages, litter boxes, and fish tanks
Long periods of bed rest
Hot and humid environments, such as saunas, greenhouses, and pools

Humidifiers must be emptied, dried, and refilled with clean fresh water daily.

Bladder

Urinary tract infections (UTI) are common among patients with low white blood cell counts. Symptoms of a UTI include:

Painful or frequent urination
Blood in the urine
Lower back or abdominal pain
Change in the odor or look of the urine

Report any of these symptoms to your doctor or nurse.

Preventive care measures for your bladder include:

Drink plenty of fluids during the day.
Empty your bladder frequently.
After a bowel movement, it is important for both men and women to clean themselves with soap and water. Women should cleanse from front to back.

Rectal area

The rectal area can contain many germs. Bacteria can enter the body easily here. Constipation can lead to straining, which can cause a tear in the rectal area or irritation of hemorrhoids. Be sure to report any symptoms of infection such as pain, burning, or itching in the rectal area, painful bowel movements, or uncomfortable hemorrhoids. Preventive care measures include:

Eat more fiber to prevent constipation.
Drink at least 5 to 6 glasses of fluid every day.
Do not use suppositories or enemas.
Wash gently with soap and water after a bowel movement.
For women, do not douche and avoid bubble baths.
For women, use sanitary pads instead of tampons during menstruation.

Sex during treatment

During periods of very low neutrophil counts, sexual intercourse is not advised. Consult your doctor or nurse about when you can have sexual relations again. Women and men should report any signs of infection, such as discharge, itching, odor, bleeding, or pain during intercourse. Preventive care measures include:

Use a water-soluble lubricant (such as K-Y Jelly, Replens) during intercourse to avoid vaginal trauma due to dryness.
Both men and women should avoid oral and anal sex.
Urinate after intercourse to decrease the risk of urinary infection.
A condom should be used to protect against infection.

Absolute Neutrophil Count (ANC)

Your doctor or nurse can tell you your ANC after you have a complete blood count. If your ANC gets very low (below 500) you should follow these precautions:

Do not go near cut flowers, dried flowers, or potted plants. Do not touch soil.
Water from the home faucet is safe if it comes from a city water supply or a municipal well serving a large population. Bottled water must state “reverse osmosis filtration” on the label. Ask your nurse for the UPMC patient information sheet “Safe-Water Guidelines for Patients with Weakened Immunity.”
Do not take a tub bath. Take showers or sponge baths.
If you have a central venous catheter, cover it with a waterproof dressing before you shower. When a central venous catheter is first inserted, allow 72 hours to pass before you take a shower, or as instructed by your surgeon.
Do not use contact lenses.
Do not get a body piercing or tattoo. If you have pierced-body jewelry, speak with your doctor or nurse about removing it.
Talk to your oncologist before you get any vaccination.
Women should check with their doctor or nurse before any gynecological exam or procedure is scheduled. Also, talk with your gynecologist about your neutropenia before your appointment.
Avoid contact with farm animals and all types of birds. These animals may carry fungal, bacterial, and viral germs. If you have a pet at home, do not come in contact with its feces or urine. Do not allow the pet to lick your face. Be sure to wash your hands after touching your pet. Do not clean fish tanks.

Avoid the following foods:

Raw fresh fruits or vegetables
Raw or rare-cooked meats, fish, and eggs
Food prepared in unknown conditions
Fast foods, deli counters, and salad bars (including macaroni salad and pasta salad)
Soft or frozen yogurt with active cultures
Fresh or dried herbs or seasonings that are added to food after cooking (pepper from individually wrapped packets may be added after cooking)
Dried fruits and raw nuts
Ask your nurse or dietitian to provide and review with you the UPMC patient information page, “Neutropenic Diet.”

How to recognize an infection

If you have an infection when your neutrophil count is low, you may not always recognize the usual warning signs (such as redness or swelling). A fever is often the first sign of an infection.
While you are at home, you should take your temperature daily. It is important to note that some medications may cover up a fever or other signs of infection. These include: steroids, aspirin and aspirin containing products (like Bayer), acetaminophen and acetaminophen-containing products (like Tylenol and Percocet), ibuprofen and ibuprofen-containing products (like Advil and Motrin).

Notify your doctor or nurse immediately if you have any of the following:

A temperature of 100.5° F or higher
Chills
A new or persistent cough, nasal congestion, sinus drainage, sore throat, or ear pain or discomfort
A toothache, white patches or ulcers in the mouth, inflamed areas or soreness in the mouth or throat
Increasing fatigue and weakness
Flushed appearance of the skin or excessive sweating
A new rash or sore, or any redness or tenderness of the skin
Slow healing of a wound or incision
Burning or urgency with urination
Redness, tearing, or draining of your eyes
Diarrhea
Difficulty waking up
Redness, drainage, swelling, or tenderness in the area of wounds or piercings
If you have a central venous catheter, redness, drainage, swelling, or tenderness along the tunnel or at the exit site
Swelling of the face, neck, or arm where the catheter is located

These are general guidelines. Your doctor or nurse may give you more specific instructions.
Specific instructions

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