From the Guidelines
Neutropenic precautions should be implemented when a patient's absolute neutrophil count (ANC) falls below 500 cells/mm³, as this is the threshold beyond which the risk of severe infection significantly increases, necessitating stricter protective measures. This guideline is supported by the Infectious Diseases Society of America's 2010 update on the use of antimicrobial agents in neutropenic patients with cancer 1. The precautions are crucial for patients undergoing chemotherapy, those with hematologic malignancies, bone marrow transplant recipients, and individuals with certain genetic disorders affecting neutrophil production. Key components of these precautions include:
- Maintaining good hand hygiene
- Avoiding raw or undercooked foods
- Avoiding fresh flowers or plants
- Limiting exposure to crowds and sick individuals
- Practicing meticulous personal hygiene Healthcare providers should monitor the patient's temperature regularly, as fever (≥38.3°C or ≥100.9°F) may be the only sign of infection in neutropenic patients, and the duration of therapy for documented infections should continue until the ANC exceeds 500 cells/mm³ or longer if clinically necessary, as outlined in the guidelines 1. The decision to implement neutropenic precautions at an ANC of 500 cells/mm³ is based on the balance between the risk of infection and the quality of life, aiming to minimize morbidity and mortality while considering the practicality of implementing such measures in real-life clinical practice.
From the FDA Drug Label
INDICATIONS AND USAGE ZARXIO is a leukocyte growth factor indicated to • Decrease the incidence of infection‚ as manifested by febrile neutropenia‚ in patients with nonmyeloid malignancies receiving myelosuppressive anti‑cancer drugs associated with a significant incidence of severe neutropenia with fever (1. 1)
Someone should be on neutropenic precautions when they have a condition that increases their risk of infection, such as:
- Receiving myelosuppressive anti-cancer drugs associated with a significant incidence of severe neutropenia with fever
- Having a nonmyeloid malignancy
- Undergoing myeloablative chemotherapy followed by bone marrow transplantation
- Having severe chronic neutropenia
These conditions increase the risk of febrile neutropenia and other infections, making neutropenic precautions necessary 2.
From the Research
Neutropenic Precautions
When someone should be on neutropenic precautions is determined by their absolute neutrophil count (ANC) and the risk of infection.
- Patients with severe neutropenia, defined as an ANC less than 0.5 × 10(9)/L, are at high risk of bacterial infections and should be treated with antibiotics and considered for prophylactic treatment with granulocyte colony-stimulating factor (G-CSF) 3.
- Patients with an ANC less than 1.5 × 10(9)/L are considered to have neutropenia and may require precautions to avoid infection, such as avoiding contact with people who are sick and avoiding certain foods that may be contaminated with bacteria 4.
- The Infectious Diseases Society of America guidelines define febrile neutropenia patients as high risk if they have an ANC ≤100 cells/µL anticipated to last >7 days 5.
- Patients with severe chronic neutropenia should take commonsense precautions to avoid infection, such as avoiding close contact with people who are sick, and should be aggressively treated for bacterial or fungal infections 4.
- Neutropenia >7 days prior to febrile neutropenia episode was an independent risk factor for bloodstream infection and increased length of stay 5.
Risk Factors
Certain factors can increase the risk of infection in patients with neutropenia, including:
- Low ANC (<0.5 × 10(9)/L) 3
- Prolonged duration of neutropenia (>7 days) 5
- Recent chemotherapy or radiation therapy 5
- Underlying medical conditions, such as congenital neutropenia or myelodysplastic syndrome 4, 6
Management
Management of neutropenia includes:
- Antibiotic treatment for febrile neutropenia 3
- Prophylactic treatment with G-CSF for patients at high risk of severe neutropenia 3
- Aggressive treatment of bacterial or fungal infections 4
- Hematopoietic stem cell transplantation for certain patients with severe congenital neutropenia or myelodysplastic syndrome 6, 7