From the Guidelines
Neutropenia precautions should be implemented when a patient's absolute neutrophil count (ANC) falls below 500 cells/mm³, as this is the threshold for severe neutropenia, which carries a high risk of infection and mortality. To determine this, obtain a complete blood count with differential and calculate the ANC by multiplying the total white blood cell count by the percentage of neutrophils (segmented neutrophils plus bands) 1. Patients at risk include those receiving chemotherapy, radiation therapy, bone marrow transplant recipients, and those with hematologic malignancies or certain genetic disorders. Implement precautions immediately upon identifying neutropenia, which typically include:
- Placing the patient in a private room
- Restricting fresh flowers and plants
- Ensuring proper hand hygiene
- Limiting visitors with infections
- Providing a low-microbial diet
- Maintaining meticulous oral care Daily monitoring of the ANC is essential for patients at risk, as the risk of infection increases with the depth and duration of neutropenia, with the greatest risk occurring in patients who experience profound, prolonged neutropenia after chemotherapy 1. These precautions are crucial because neutropenic patients have a compromised immune system, making them highly susceptible to infections that can rapidly become life-threatening, with mortality rates from neutropenic sepsis reaching up to 11% in the context of febrile neutropenia 1.
From the FDA Drug Label
Cyclophosphamide can cause myelosuppression (leukopenia, neutropenia, thrombocytopenia and anemia), bone marrow failure, and severe immunosuppression which may lead to serious and sometimes fatal infections, including sepsis and septic shock. Cyclophosphamide should not be administered to patients with neutrophils ≤1,500/mm 3 and platelets < 50,000/mm 3.
Neutropenia Precautions: Place someone on neutropenia precautions when their neutrophil count is ≤1,500/mm^3.
- Key factors to consider:
- Neutrophil count: Monitor complete blood counts during cyclophosphamide treatment.
- Platelet count: Cyclophosphamide should not be administered to patients with platelets < 50,000/mm^3.
- Infection risk: Antimicrobial prophylaxis may be indicated in certain cases of neutropenia at the discretion of the managing physician 2.
From the Research
Neutropenia Precautions
To determine when to place someone on neutropenia precautions, several factors should be considered:
- The patient's absolute neutrophil count (ANC) is a key indicator of neutropenia risk 3
- The timing and grade of chemotherapy-induced neutropenia (CIN) may play prognostic and predictive roles in cancer therapy 4
- Patient characteristics such as older age, poor functional and nutritional status, and presence of significant comorbidities can increase the risk of CIN 4
- The type of cancer, previous chemotherapy cycles, and specific chemotherapy regimens can also impact the risk of neutropenia 4
Assessment Tools
Several assessment tools are available to help stratify the risk of complications in patients with febrile neutropenia, including:
- The Multinational Association for Supportive Care in Cancer (MASCC) score
- The Clinical Index of Stable Febrile Neutropenia (CISNE) score model 4
- These tools can help identify patients at high risk of neutropenic events and guide the use of prophylactic treatments such as granulocyte-colony stimulating factor (G-CSF) 3, 5
Timing of Chemotherapy
The timing of cyclic cytotoxic chemotherapy can worsen neutropenia and neutrophilia, and delaying supportive G-CSF therapy to 6-7 days after chemotherapy can mitigate myelosuppressive effects 5
- Quantitative systems pharmacology models can help optimize therapy schedules to reduce the risk of neutropenia and febrile neutropenia 5