Neutropenia: A Vulnerable Time for Infections

What Is Neutropenia?

There are many types of white blood cells, each with specific roles, but their main job is to fight infection. Neutropenia is a condition in which there are very low amounts of white blood cells in the body, especially neutrophils. Neutrophils are abundant in a healthy person, making up about 70 percent of all white cells in the body. Since white blood cells attack harmful bacteria, viruses, and fungi, neutropenia increases the risk of infections.

Who Is at Risk?

Neutropenia is often seen in people receiving chemotherapy or radiation, which can temporarily weaken the immune system or cause myelosuppression, the slowing down of normal production of blood cells.

The specific type of treatment influences neutropenia. It also depends on the disease, the stage of the cancer, and where it is located Also at high risk are those undergoing bone marrow transplants (BMT) that require myelosuppressive chemotherapy treatments, sometimes with total body irradiation (TBI).

Neutropenic effects can accumulate over the years. If you've received round after round of chemotherapy, you are at risk. If you start the current treatment with an already weak immune system, you're also at risk. Age and nutritional status are other contributing factors.

Damage to blood cells from radiation depends on the dose given, and if the radiation beams are targeted at the bone marrow or other major areas that make white blood cells. These areas include the ileac crest, or upper part of the hip; the sternum, which includes the area of bones in the center of the chest; and any long bones, such as the top of the thighbone. A person receiving TBI may become neutropenic, because the radiation targets many areas at once that produce blood cells.

Preventing Infections

If patients are at high risk for neutropenia, doctors may give them medication for an infection before it actually develops. Antibiotics that cover a broad range of bacteria are often used as a preventive treatment for neutropenia. Doctors may refer to this type of preventive treatment as prophylactic treatment.

The overuse of antibiotics causing resistant strains of bacteria is concerning, but the consequences of not using them are of greater concern. Infections can cause a delay in chemotherapy or radiation treatment that may negatively affect its long-term effectiveness.

Defining Neutropenia

Neutrophils are measured by the absolute neutrophil count (ANC). The normal range for neutrophils is 2500 to 6000/mm3. Neutropenia occurs when the ANC is less than 1000/mm3. There is high risk of infection when the ANC drops below 500/mm3, and a severe risk when the ANC falls below 100/mm3. The longer people are neutropenic and the lower the level of neutrophils, the greater their risk of infection.

The lowest level of white blood cells after chemotherapy usually occurs ten to fourteen days after treatment. This is called the nadir period. although the nadir period is usually predictable, each patient can react differently to treatment and some people might reach this phase earlier or later.

After the nadir period, blood cells are replenished to normal levels in about three to four weeks. Recovery may take longer if there is a combination of myelosuppressive drugs used or if the person has a weak immune system.

Stimulating Blood With Growth Factors

Hematopoietic growth factors (HGF), granulocyte colony stimulating factors (G-CSF), or granulocyte-macrophage colony stimulating factors (GM-CSF) are also used to prevent or treat infections. HGF and CSF are natural proteins in the body that encourage the growth and activity of neutrophils and other blood cells. They can help shorten the length and severity of the nadir period. HGF or CSF is given once daily starting the day after chemotherapy. Side effects may include bone pain, fever, and general malaise.

Consequences of Infection

The nadir period is when a person is most vulnerable to getting infections. People with neutropenia may have diarrhea, mucositis (irritation of the lining of the mouth), problems with body organs, and fever. A fever requires immediate medical attention or septic shock can occur, a potentially serious and deadly condition in which bacteria quickly spread in the blood throughout the body.

patients may be told to check their temperature twice daily and report any temperature of 100.5 F or higher to their doctor right away.

How to Protect Yourself if You Are Neutropenic

Good personal hygiene and avoiding things that promote the growth of bacteria lower the risk of infection. The following suggestions are for people with neutropenia who are outside the hospital:

• Avoid people with signs of infection and large crowds. Wear a face mask if you cannot avoid crowds.

• Avoid people who are sick with communicable (contagious) diseases, including a cold, the flu, measles, or chicken pox.

• Stay away from children who have recently been given "live virus" vaccines such as chicken pox and oral polio, as they may be contagious to people with very low blood cells counts.

• Bathe daily and wash hands frequently, especially after using the bathroom, after touching animals, and before eating.

• Use lotion or oil if your skin becomes dry.

• Clean your rectal area gently but thoroughly after each bowel movement. Let you doctor know if the area becomes irritated or if you develop hemorrhoids.

• Brush your teeth after meals with a soft toothbrush. Rinse your mouth twice daily with a solution made of water and either salt or baking soda. Temporarily avoid flossing, which can open new wounds and create an entry for bacteria.

• Avoid accidents and injuries. Be careful not to cut yourself in any way, including the cuticles of your nails. Use an electric shaver instead of a razor to avoid cutting yourself while shaving.

• Do not squeeze or scratch pimples.

• Clean any cuts and scrapes with soapy warm water right away and apply an antiseptic.

• Avoid gardening, cleaning bird cages, cleaning fish tanks, or changing cat litter, all of which can expose you to bacteria .

For very high-risk neutropenic patients who are admitted to the hospital for more than one week, such as with bone marrow transplants, the restrictions are more stringent. The patient usually stays in an isolated room, and visitors must wash their hands and wear gloves and face masks. Patients will eat a low-bacteria diet that excludes all fresh fruits, vegetables, and undercooked meats and eggs. They must also avoid fresh cut flowers or plants that can harbor bacteria and fungi.

Warning Signs to Get Medical Attention

It is critical for people with neutropenia to check closely for signs of infection and report to their doctor or emergency room immediately with the following symptoms:

• A fever of 100.5° F (38°C)

• Persistent cough

• Shortness of breath

• Burning or pain with urination, or a desire to urinate frequently

• Sore mouth or throat

• Blisters on the lips or skin

• Sinus pain or pressure

• Shaking or chills

• Sweating

• Earaches, headaches, or stiff neck

• Diarrhea or constipation

• Unusual vaginal discharge or itching

• Any area with unusual redness or swelling

• A change in mental status