Low White Blood Cell Count/Neutropenia

Carolyn Vachani RN, MSN, AOCN
Abramson Cancer Center of the University of Pennsylvania
Last Modified: January 27, 2011

White blood cells (WBC) are one part of our body's immune system, working to protect us against infection. A neutrophil is one type of WBC and they make up the majority of WBCs. They are the "first responders" and quickly appear at the site of infection, ingesting and destroying foreign particles. They can be found in the pus of a wound and play a role in acute inflammation (redness, warmth, swelling, and pain). A normal neutrophil count (also called absolute neutrophil count or ANC) is between 2500 and 5000. A low neutrophil count (less than 1000) is known as neutropenia. The lower the neutrophil count, the higher the risk of infection. Neutropenia is most often caused by cancer therapies, including chemotherapy and radiation therapy. Ask your healthcare team when your counts are likely to be at their lowest (also called nadir), as you will most likely be at home during the nadir. For chemotherapy, low counts usually occur 7-10 days after treatment.

Given that neutropenia is caused by cancer treatments, there is not much you can do to prevent it from occurring, but you can decrease the risk of getting an infection while your count is low.

Steps to help prevent infection:

  • Hand washing, hand washing, hand washing! This includes the patient and those around the patient.
  • Avoid large crowds where you may come into contact with germs, such as shopping malls, church, or public transportation. If need be, go at off peak hours to avoid the crowds.
  • Avoid anyone who is sick (including colds), including other people in their household are sick.
  • Avoid children or adults who have recently received vaccines.
  • If you have a central catheter (PICC, Port, Hickman), use caution to keep it clean and dry. Check the area for redness or tenderness (soreness) daily.
  • Follow an oral care regimen.
  • Wear sunscreen (SPF 15 or higher) to prevent sunburn.
  • Use only electric razors to prevent cuts.
  • Use caution to avoid any cuts or injuries. (avoid contact sports, wear gloves for household chores)
  • Do not use rectal suppositories.
  • Do not have dental work without first talking with your healthcare team.
  • Do not get any vaccines without first talking with your healthcare team.
  • Women should not use tampons while neutropenic as these can pose a risk of infection and toxic shock syndrome. Use sanitary napkins instead.
  • Neutropenic patients should not have intercourse, any type of vaginal or anal penetration (including toys/props) or oral sex as these can pose an infection risk. Talk with your healthcare providers if you have specific sexual practices that you are concerned about.

You may receive a growth factor to stimulate neutrophil production. This is a man-made version of a natural hormone that causes the body to produce more neutrophils. It is given by an injection just under the skin. There are a few growth factors available in the United States: filgrastim (Neupogen®), pegfilgrastim (Neulasta®) and sargramostim (Leukine®).

Even the best hand washers end up with an infection. An infection in a neutropenic patient is an emergency! If you notice any signs or symptoms of infection, you should call your doctor right away - even if it is the middle of the night. Make sure you know how to reach someone when the office is closed!

Signs and symptoms of infection to look for:

  • Check your temperature twice a day or if you feel feverish. If your temperature is above 100.4, call your doctor right away.
  • Do not take acetaminophen (Tylenol) or aspirin to reduce the fever without talking to your doctor first.
  • Shaking chills
  • Cough, sore throat, shortness of breath
  • Burning with urination or new lower back pain
  • Blood in urine
  • Diarrhea (worsening) or change in the odor of your stool
  • Rash, redness or swelling of the skin
  • Redness, soreness around central line catheter, feeding tube or a wound
  • Soreness or swelling in your mouth or throat, ulcers or white patches in your mouth, or a change in the color of your gums

You may be told to follow a neutropenic diet. This diet is intended to decrease your exposure to bacteria. A basic neutropenic diet includes:

  • Avoid all fresh fruits and vegetables. Cooked vegetables and canned fruits and juices are fine. You may eat fruit that you can peel a thick skin off of, such as a banana or an orange.
  • Avoid raw or rare-cooked meat, fish, and eggs. Meat should be cooked to the "well done" stage. All eggs should be thoroughly cooked (no runny yolks).
  • Avoid salad bars, fruit bars, and deli counters. Buy vacuum-packed lunch meats rather than freshly sliced meats.
  • Eat or drink only pasteurized milk, yogurt, cheese or other dairy products.
  • Avoid soft mold-ripened and blue-veined cheese including: Brie, Camembert, Roquefort, Stilton, Gorgonzola, Bleu.
  • At home, you may use tap water or bottled water. Avoid well water or boil it for 1 minute before using.

Every cancer center has different rules regarding the neutropenic diet. Be sure to ask your healthcare team for any special instructions. Patients undergoing bone marrow or stem cell transplant will have a stricter diet. Remember this diet is only temporary while your blood counts are low. Wash your hands well before preparing any food and keep your work area clean.

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