What precautions should be taken for patients with neutropenia?

Neutropenia Precautions

Hand hygiene is the most effective means of preventing transmission of infection in neutropenic patients and should be strictly enforced for all patients, healthcare workers, and visitors. 1

Risk Stratification and General Precautions

Neutropenia precautions should be tailored based on risk level:

Low Risk

• Standard chemotherapy for most solid tumors
• Neutropenia <7 days
• Precautions:
  • No specific antibiotic prophylaxis needed
  • Standard infection control measures
  • No specific dietary restrictions required

Intermediate Risk

• Autologous HCT, lymphoma, multiple myeloma, CLL
• Neutropenia 7-10 days
• Precautions:
  • Consider fluoroquinolone prophylaxis during neutropenia
  • Consider antifungal prophylaxis, especially with mucositis
  • Consider PJP prophylaxis

High Risk

• Allogeneic HCT, acute leukemia, neutropenia >10 days
• Precautions:
  • Fluoroquinolone prophylaxis during neutropenia
  • Antifungal prophylaxis
  • PJP prophylaxis
  • Enhanced viral prophylaxis 1

Specific Infection Control Measures

Isolation and Barrier Precautions

• Standard barrier precautions for all patients
• HSCT recipients should be placed in private rooms
• Allogeneic HSCT recipients require rooms with >12 air exchanges/hour and HEPA filtration
• No specific protective gear (gowns, gloves, masks) required for routine care unless contact with body fluids is anticipated 1

Food Safety

• Well-cooked foods are preferred
• Avoid prepared luncheon meats
• Well-cleaned, uncooked raw fruits and vegetables are acceptable
• Cooked foods from home or restaurants are acceptable if freshness and preparation can be confirmed 1

Environmental Precautions

• Plants and dried or fresh flowers should not be allowed in rooms of hospitalized neutropenic patients due to risk of mold exposure (Aspergillus, Fusarium)
• Household pets should not be allowed on wards housing neutropenic patients
• Healthcare workers and visitors with transmissible infections should avoid patient contact or use appropriate barrier protection 1

Patient Care Recommendations

Skin and Oral Care

• Daily showers or baths to optimize skin integrity
• Daily inspection of potential infection portals (perineum, IV access sites)
• Maintain good perineal hygiene with thorough cleaning after bowel movements
• Females should wipe from front to back after using toilet
• Avoid tampons in menstruating patients
• Oral rinses 4-6 times daily with sterile water, normal saline, or sodium bicarbonate for patients with mucositis
• Brush teeth >2 times daily with soft toothbrush
• Avoid rectal thermometers, enemas, suppositories, and rectal examinations 1

Contraindicated Procedures

• Rectal thermometers
• Enemas
• Suppositories
• Rectal examinations
• Fixed orthodontic appliances during periods of mucositis 1

Management of Severe Neutropenia

For patients with severe neutropenia (ANC <500/μL) or neutropenia with fever:

• Prompt evaluation for infection
• Cultures and radiological tests
• Initiation of broad-spectrum empirical antibiotics within 2 hours of presentation
• Consider G-CSF (filgrastim) at 5 mcg/kg/day for chemotherapy-induced neutropenia to reduce duration and complications 1, 2

Common Pitfalls to Avoid

1. Delaying antibiotic administration in febrile neutropenia (should be given within 2 hours)
2. Neglecting hand hygiene, which is the most effective preventive measure
3. Allowing plants or flowers in patient rooms
4. Using rectal thermometers or performing rectal examinations
5. Failing to recognize the different precaution requirements based on risk stratification

By following these evidence-based precautions, the risk of infection in neutropenic patients can be significantly reduced, leading to improved morbidity, mortality, and quality of life outcomes.