What is the management plan for a patient with elevated neutrophils (neutrophilia)?

Management of Neutrophilia

Elevated neutrophils require immediate assessment for bacterial infection through targeted history, physical examination, and diagnostic testing, with prompt empirical antibiotic therapy initiated when clinical signs of infection are present. 1

Initial Clinical Assessment

When evaluating neutrophilia, focus on these specific clinical features:

• Check for fever, hypotension, or tachycardia - these indicate potential sepsis requiring immediate intervention, even with low-grade temperature or absence of fever in Gram-negative septicemia 2
• Examine for localized infection sources: respiratory symptoms (pneumonia), urinary symptoms (UTI), skin/soft tissue lesions, abdominal pain, or altered mental status 1
• Review medication history for drugs causing neutrophilia: lithium, beta-agonists, or epinephrine 1
• In cirrhotic patients with ascites, assess for abdominal pain, confusion, fever, or worsening liver/renal function suggesting spontaneous bacterial peritonitis 2

Diagnostic Workup

Laboratory Testing Priority

Order these tests immediately:

• Complete blood count with manual differential to assess absolute neutrophil count, band count, and left shift 1
• Blood cultures (minimum two sets) before starting antibiotics if systemic infection suspected 2, 1
• C-reactive protein to assess inflammatory status 3

Interpretation of Neutrophil Elevation

The diagnostic power for bacterial infection follows this hierarchy 1:

• Absolute band count ≥1,500 cells/mm³ has the highest likelihood ratio (14.5) for bacterial infection
• Neutrophil percentage >90% has likelihood ratio of 7.5
• Left shift ≥16% bands has likelihood ratio of 4.7, even with normal total WBC
• Total WBC ≥14,000 cells/mm³ has likelihood ratio of 3.7

Critical pitfall: Do not ignore neutrophilia when total WBC is normal - left shift can occur with normal WBC and still indicate serious bacterial infection 1

Site-Specific Testing

Based on clinical presentation 1, 3:

• Respiratory symptoms: chest imaging and sputum culture 2
• Urinary symptoms: urinalysis with culture 1
• Abdominal symptoms in cirrhosis: diagnostic paracentesis mandatory 2
• Skin lesions: aspirate, biopsy, or swab 2

Special Population: Cirrhosis with Ascites

Perform diagnostic paracentesis immediately in these situations 2:

• All cirrhotic patients with ascites at hospital admission
• Gastrointestinal bleeding, shock, or fever
• Signs of systemic inflammation or altered white blood cell count
• Worsening liver/renal function or hepatic encephalopathy

Diagnosis of spontaneous bacterial peritonitis: neutrophil count >250/mm³ in ascitic fluid 2

Initiate empirical antibiotics immediately after diagnosis without waiting for culture results 2

• First-line: Cefotaxime 2g IV every 12 hours for 5 days (as effective as 10 days) 2
• Alternative: Amoxicillin/clavulanic acid or ceftriaxone 2
• Avoid aminoglycosides due to nephrotoxicity 2

Add albumin 1.5 g/kg within 6 hours, then 1g/kg on day 3 if signs of renal impairment 2

Empirical Antibiotic Therapy Algorithm

When to Start Antibiotics Immediately

Initiate broad-spectrum antibiotics without delay if: 1, 3

• Fever with neutrophilia present
• Clinical signs of infection (hypotension, tachycardia, respiratory distress)
• Neutrophil count >250/mm³ in ascitic fluid (cirrhotic patients)
• Immunocompromised state (cancer patients with fever)

Antibiotic Selection

• Community-acquired infections: Cover common bacterial pathogens (E. coli, Streptococcus, Enterococcus) 2
• Healthcare-associated infections: Consider resistant organisms based on prior microbiology 2
• Adjust therapy based on culture results when available 3

Monitoring and Follow-Up

Reassess at 48-72 hours 3:

• Clinical status improvement
• Repeat laboratory parameters
• Culture results to guide antibiotic adjustment

Consider stopping antibiotics if patient afebrile for 48 hours by day 3 with no definite infection site and negative cultures 3

Common Pitfalls to Avoid

• Delaying antibiotics while waiting for culture results in symptomatic patients 3
• Overlooking absolute neutrophil count elevation when total WBC only mildly elevated 1
• Treating asymptomatic patients with antibiotics based solely on mild neutrophil elevation 1
• Missing intracellular pathogens (Salmonella) when monocytosis accompanies neutrophilia 3
• Failing to perform paracentesis in cirrhotic patients with ascites and altered WBC 2