What precautions should be taken when a patient has Neutropenia?

Neutropenia Precautions

For patients with neutropenia, implement strict hand hygiene protocols, avoid rectal procedures and fresh flowers/plants, provide antimicrobial prophylaxis based on risk stratification (fluoroquinolone for expected neutropenia >7 days), and initiate G-CSF when appropriate—but routine protective isolation with gowns/gloves/masks is NOT necessary for most neutropenic patients. 1

Hand Hygiene: The Single Most Critical Intervention

• All persons—healthcare workers, visitors, and family—must sanitize hands before entering and after leaving patient rooms 1
• Hand hygiene is more important than any other infection control measure 1
• Standard barrier precautions only; no special protective gear (gowns, gloves, masks) required during routine care for most neutropenic patients 1

Risk Stratification for Antimicrobial Prophylaxis

The approach to prophylaxis depends entirely on the expected duration and depth of neutropenia (defined as ANC ≤500/mcL or ≤1000/mcL with predicted decline to ≤500/mcL within 48 hours) 2:

Low Risk (Neutropenia <7 days)

• No antibacterial prophylaxis recommended 2
• No antifungal prophylaxis 2
• No antiviral prophylaxis unless prior HSV episode 2
• This includes most patients with solid tumor malignancies on standard chemotherapy 2

Intermediate Risk (Neutropenia 7-10 days)

• Consider fluoroquinolone prophylaxis (levofloxacin preferred) during neutropenia 2
• Consider antifungal prophylaxis during neutropenia and for anticipated mucositis 2
• Consider PJP prophylaxis 2
• Antiviral prophylaxis during neutropenia and longer depending on risk 2
• Examples: autologous HCT, lymphoma, multiple myeloma, CLL, purine analog therapy, CAR T-cell therapy 2

High Risk (Neutropenia >10 days)

• Fluoroquinolone prophylaxis strongly recommended during neutropenia 2
• Antifungal prophylaxis during neutropenia 2
• PJP prophylaxis 2
• Antiviral prophylaxis during neutropenia and longer depending on risk 2
• Examples: allogeneic HCT, acute leukemia (induction/consolidation), alemtuzumab therapy, moderate-to-severe GVHD 2

For fluoroquinolone-intolerant patients, consider TMP/SMX or an oral third-generation cephalosporin 2

Specific Antimicrobial Prophylaxis Regimens

Antibacterial

• Levofloxacin or ciprofloxacin 500 mg orally daily starting with onset of neutropenia 2
• Continue until ANC >500/mcL 2
• Important caveat: Fluoroquinolone use is associated with severe C. difficile and MRSA infections, so use judiciously 2

Antifungal

• Fluconazole 400 mg orally daily starting day of stem cell infusion (or equivalent timing) 2
• Continue until ANC >1000/mcL 2

Antipneumocystis

• TMP/SMX orally three times per week 2
• Continue for 6 months (at least 3 months) post-treatment and/or until CD4 >200 cells/mm³ 2

Antiviral

• Acyclovir 400 mg or valacyclovir 500 mg orally twice daily 2
• Continue for 6 months (at least 3 months) post-treatment and/or until CD4 >200 cells/mm³ 2

Environmental and Patient Care Precautions

Absolutely Prohibited

• No rectal thermometers, enemas, suppositories, or rectal examinations 2, 1
• No plants, dried flowers, or fresh flowers in patient rooms (risk of Aspergillus and Fusarium from soil) 2, 1
• No household pets on wards housing neutropenic patients 2, 1
• No tampons during menstruation (risk of abrasion) 2, 1

Daily Hygiene Requirements

• Daily showers or baths during hospitalization 2, 1
• Daily inspection of high-risk infection sites: perineum and IV access sites 2, 1
• Gentle but thorough perineal cleaning after bowel movements with complete drying 2, 1
• Females must wipe front to back after toileting 2, 1

Oral Care Protocol

• Brush teeth >2 times daily with a soft regular toothbrush 2, 1
• If regular brushing cannot be tolerated, use ultrasoft toothbrush or foam swab (though less effective at debris removal) 2
• Oral rinses 4-6 times daily with sterile water, normal saline, or sodium bicarbonate solution, especially with mucositis 2, 1
• Daily flossing acceptable if done without trauma 2, 1
• Remove fixed orthodontic appliances until mucositis resolves 2, 1

Dietary Precautions

• Well-cooked foods recommended 1
• Avoid prepared luncheon meats 1
• Well-cleaned raw fruits and vegetables are acceptable 1

Room Requirements and Isolation

Common pitfall: Most neutropenic patients do NOT require private rooms or special isolation 1

• Single-patient rooms NOT required for most neutropenic patients 1
• Exception: HSCT recipients require private rooms with >12 air exchanges/hour and HEPA filtration 1
• Standard barrier precautions sufficient for routine care 1

Visitor and Healthcare Worker Restrictions

• Symptomatic HCWs or visitors with transmissible infections (VZV, gastroenteritis, HSV lesions, upper respiratory infections) must not provide care or visit unless appropriate barriers established 2, 1
• Vaccination of HCWs and visitors recommended: annual influenza, MMR, varicella if indicated 2, 1
• Work exclusion policies should encourage HCWs to report illnesses or exposures 2

G-CSF Administration

G-CSF (filgrastim) is strongly recommended to reduce myelosuppression, infections, and hospitalization duration 2:

• Initiate the day after TIL infusion or chemotherapy completion 2
• Dose: 5-10 mcg/kg/day subcutaneously 3
• Continue until ANC ≥500/mm³ 2
• This differs from CAR T-cell therapy where G-CSF requires caution due to CRS risk 2

Febrile Neutropenia Management

All febrile neutropenic patients require urgent evaluation and treatment within 2 hours of presentation 2, 1:

• Obtain blood and urine cultures 2
• Chest X-ray and sputum analysis if pulmonary symptoms present 2
• Initiate broad-spectrum empirical antibiotics within 2 hours 2, 1
• Broad-spectrum coverage must include activity against gram-negative bacteria (especially Pseudomonas aeruginosa) 2
• If fever develops while on fluoroquinolone prophylaxis, withdraw fluoroquinolone and escalate to broader coverage 2

Surveillance

• Routine environmental surveillance cultures should NOT be performed in absence of infection clusters 2, 1
• Monitor for aspergillosis cases: ≥2-fold increase in attack rate during any 6-month period warrants environmental investigation 2