Low White Blood Cell Count (Neutropenia)

White blood cells (WBC) are part of our body's immune system. These cells protect us against infection. A neutrophil is one type of WBC and makes up most of our WBCs. They are the "first responders" and quickly go to the site of infection, taking in and destroying foreign particles (something not found in the body). 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 2,500 and 6,000.
• A low neutrophil count (less than 1,000) is known as neutropenia. The lower the neutrophil count, the higher the risk of infection.

Neutropenia is most often caused by cancer therapies, like chemotherapy and radiation therapy. Ask your healthcare team when your counts are likely to be at their lowest (called your nadir), as you will most likely be at home during the nadir. For chemotherapy, low counts happen about 7-12 days after treatment. If you are in the hospital during your nadir, you will likely be placed on “neutropenic precautions.” These are guidelines set by the hospital staff and your oncology team to keep you safe from infection.

There are ways you can lessen the risk of getting an infection while your count is low.

Steps to prevent infection:

• Hand washing, hand washing, hand washing! This includes you and those around you (healthcare workers, caretakers, family members, and visitors).
• Avoid large crowds where you may come in contact with germs, such as in shopping malls, churches, or buses and trains. If you must, go at off-peak hours to avoid the crowds.
• Avoid anyone who is sick including other people in your household that are sick.
• Avoid children or adults who have recently gotten vaccines.
• Do not handle animal waste (including cat litter, birdcage waste, fish tank water, chicken coops, etc.)
• If you have a central catheter (PICC, Port, Hickman), keep it clean and dry. Check the area for redness or tenderness (soreness) daily.
• Follow an oral care regimen. Use a soft-bristled toothbrush.
• Wear sunscreen (SPF 15 or higher) to prevent sunburn.
• Use only electric razors to avoid cuts that can become infected.
• Be aware of 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. Tampons 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 worried about.

You may receive a medication called a granulocyte colony stimulating factor, or GCSF, which stimulates (revs up) neutrophil production. This is a man-made version of a natural hormone that causes the body to make 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 can 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 provider right away - even if it is the middle of the night. You will likely need to have blood work drawn and other testing to look for a source of infection. It is important to receive antibiotics as soon as possible since your immune system is weakened (immunocompromised) and unable to fight some infections on its own. Make sure you know how to reach your healthcare team when the office is closed!

Signs and symptoms of infection to look for:

• Check your temperature twice a day or any time you feel feverish (skin warm to the touch, chills, facial flushing). If your temperature is 100.4°F (38.0°C) or higher, call your provider right away.
• Do not take acetaminophen (Tylenol) or aspirin to reduce the fever without talking to your provider first.
• Shaking chills.
• Cough, sore throat, nasal congestion, or shortness of breath.
• Burning with urination or new lower back pain.
• Blood in the 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.

Practice Food Safety

While your immune system is working to get back to normal, you may have a harder time fighting a food-borne illness. There are some steps you can take to make food safety a priority:

• Wash all fresh fruits and vegetables well before eating or cooking.
• Avoid raw or rare-cooked meat and fish. Meat should be cooked to safe internal temperatures.
• Use only pasteurized eggs, milk, yogurt, cheese, other dairy products, fruit juices, and honey. Cook eggs all the way through.
• Avoid soft mold-ripened and blue-veined cheese like Brie, Camembert, Roquefort, Stilton, Gorgonzola, and Bleu.
• Hot dogs, lunch meats, and deli meats should be reheated to steaming hot or 165°F (73.9°C) degrees.
• Pay attention to “sell by” or “use by” dates.
• Follow these 4 basic steps for food safety:
  • Clean - Wash your hands well before preparing any food and keep your work area clean.
  • Separate - Don’t cross-contaminate (mix foods while prepping). Keep raw meat and poultry apart from cooked foods.
  • Cook - Use a food thermometer to be sure meat and poultry are safely cooked.
  • Chill - Refrigerate or freeze food right away.

Every cancer center follows different rules for a neutropenic safe diet. Be sure to ask your healthcare team for any special instructions. Patients having a bone marrow or stem cell transplants often have stricter dietary rules. Remember, this diet is only short-term while your blood counts are low.