Neutropenia

Managing low white blood cell counts and preventing infections during cancer treatment

Normal ANC

1,500-8,000/μL

Nadir Timing

7-14 days post-chemo

Recovery

21-28 days typically

Emergency Temp

≥100.4°F (38°C)

Understanding Neutropenia

Neutropenia is a condition where you have an abnormally low number of neutrophils, the white blood cells that fight bacterial infections. It's one of the most common and serious side effects of chemotherapy.

Key Definitions

Neutrophils: Type of white blood cell that fights infection
ANC (Absolute Neutrophil Count): Total number of neutrophils in blood
Nadir: Lowest point of blood counts after treatment
Febrile neutropenia: Fever with low neutrophil count (medical emergency)

How ANC is Calculated

ANC = WBC × (% Neutrophils + % Bands) / 100

Example: WBC of 3,000 with 50% neutrophils and 5% bands

ANC = 3,000 × (50 + 5) / 100 = 1,650/μL

Why Neutropenia Occurs

Chemotherapy damages rapidly dividing cells
Bone marrow temporarily stops producing neutrophils
Some cancers directly affect bone marrow
Radiation to large bones can affect production

Risk Assessment

Normal/Low Risk

ANC >1,500/μL

Normal infection risk

Mild Neutropenia

ANC 1,000-1,500/μL

Slightly increased risk

Moderate

ANC 500-999/μL

Significant risk

Severe

ANC <500/μL

High infection risk

Factors Increasing Risk

Treatment factors:
- High-dose chemotherapy
- Multiple chemotherapy agents
- Previous chemotherapy cycles
- Concurrent radiation
Patient factors:
- Age >65 years
- Poor nutritional status
- Open wounds or catheters
- Existing infections
- Other medical conditions
Cancer factors:
- Blood cancers (leukemia, lymphoma)
- Extensive bone marrow involvement
- Advanced disease

Signs and Symptoms

Important: Neutropenia Often Has NO Symptoms

You cannot feel if your white blood cell count is low. Regular blood tests are essential.

Signs of Infection to Watch For

Fever: Temperature ≥100.4°F (38°C) or as directed
Chills or shaking
Sore throat or mouth sores
Cough or shortness of breath
Nasal congestion
Burning with urination
Redness, swelling, or drainage from any site
Diarrhea
Unusual vaginal discharge or itching
Pain in abdomen or rectum

📌 Temperature Taking Guidelines

Use a digital thermometer (oral or ear)
Do NOT use rectal thermometers (infection risk)
Check temperature if you feel warm, cold, or unwell
Keep a temperature log
Know your doctor's specific temperature threshold

Emergency Warning Signs

🚨 CALL 911 or GO TO ER IMMEDIATELY IF:

Fever ≥100.4°F (38°C) - This is a medical emergency with neutropenia
Chills or uncontrollable shaking
Confusion or mental changes
Difficulty breathing or chest pain
Severe abdominal pain
Blood pressure changes or dizziness
Decreased urination
Rapid heart rate

DO NOT WAIT - Infections can progress rapidly when neutropenic

Tell medical staff immediately that you are receiving chemotherapy and may be neutropenic

What to Bring to the ER

List of current medications
Oncologist's contact information
Recent blood count results if available
Chemotherapy treatment card
Insurance information

Infection Prevention Strategies

Hand Hygiene

Wash hands frequently with soap and water
Wash for at least 20 seconds
Use alcohol-based sanitizer when soap unavailable
Wash before eating and after bathroom
Ask visitors to wash hands
Avoid touching face

Social Precautions

Avoid crowds and sick people
Stay away from children with vaccines (live)
Wear mask in public if ANC <500
Limit visitors
No handshaking or hugging
Avoid public transportation if possible

Personal Hygiene

Shower or bathe daily
Use soft toothbrush
No flossing if platelets low
Keep nails short and clean
Use electric razor, not blade
Moisturize to prevent skin cracks

Environmental

Clean surfaces regularly
Change bed linens frequently
No fresh flowers or plants
No cleaning litter boxes
Avoid construction areas
No gardening or yard work

Medical Care

No dental work without approval
No vaccines without approval
Avoid suppositories/enemas
No rectal temperatures
Report any procedures to oncologist
Prophylactic antibiotics if prescribed

Pet Safety

Avoid pet waste cleanup
No litter box cleaning
Keep pets clean and groomed
Avoid scratches and bites
No new pets during treatment
No reptiles, birds, or rodents

Neutropenic Diet Guidelines

Food Safety During Neutropenia

When ANC <1,000/μL, follow these dietary precautions:

AVOID	SAFE ALTERNATIVES
Raw or undercooked meat, poultry, fish, eggs	Well-cooked meats (165°F internal temp)
Raw or unpasteurized dairy products	Pasteurized milk, cheese, yogurt
Soft cheeses (brie, feta, blue cheese)	Hard cheeses, processed cheese
Raw vegetables and salads	Cooked vegetables, canned fruits
Fresh fruits that can't be peeled	Peeled fruits, cooked/canned fruits
Raw nuts, dried fruits	Roasted nuts, cooked fruits
Deli meats, hot dogs (unless reheated)	Freshly cooked meats
Buffets, salad bars, potlucks	Freshly prepared home meals
Raw honey, herbal supplements	Pasteurized honey, approved supplements
Tap water (if not safe)	Boiled or bottled water

Food Preparation Tips

Wash hands before food preparation
Use separate cutting boards for raw meat
Cook to proper temperatures (use thermometer)
Refrigerate leftovers within 2 hours
Eat leftovers within 24-48 hours
When in doubt, throw it out
Check expiration dates

Medications and Growth Factors

💊 Growth Factor Support (G-CSF)

Medications that stimulate white blood cell production:

Filgrastim (Neupogen): Daily injections
Pegfilgrastim (Neulasta): Once per cycle
Pegfilgrastim on-body injector (Onpro): Automatic delivery
Biosimilars: Zarxio, Udenyca, Fulphila, others

When Growth Factors Are Used

Primary prophylaxis: High-risk regimens (>20% risk)
Secondary prophylaxis: After neutropenic event
Treatment: For prolonged neutropenia

Growth Factor Side Effects

Bone pain (common - treat with acetaminophen)
Headache
Muscle aches
Injection site reactions
Low-grade fever

Prophylactic Antibiotics

May be prescribed if high risk:

Fluoroquinolones (levofloxacin, ciprofloxacin)
Antifungal prophylaxis if very high risk
Antiviral prophylaxis if history of herpes

Daily Living Precautions

Daily Checklist When Neutropenic

Check temperature twice daily
Inspect mouth for sores
Check skin for cuts, redness, swelling
Practice meticulous hand hygiene
Take prescribed medications
Follow neutropenic diet
Avoid crowds and sick contacts
Get adequate rest
Stay hydrated
Report any symptoms immediately

Household Activities

Safe: Light housework, laundry, cooking (with precautions)
Avoid: Gardening, cleaning pet areas, dusty areas
Use gloves: When cleaning, handling raw meat
Ventilate: When using cleaning products

Work and School

Discuss with doctor about work/school attendance
Avoid if ANC <500 or as directed
Consider work from home if possible
Avoid sick coworkers
Private office better than open spaces

Monitoring and Follow-up

📅 Typical Blood Count Timeline

Day 0: Chemotherapy given
Days 7-10: Counts begin to drop
Days 10-14: Nadir (lowest point)
Days 14-21: Recovery begins
Days 21-28: Return to baseline

Blood Test Schedule

Before each chemotherapy cycle
Weekly or biweekly during treatment
More frequently if neutropenic
Before procedures or dental work

What Your Doctor Monitors

Absolute neutrophil count (ANC)
Total white blood cell count
Trends over time
Recovery pattern
Need for dose modifications

When to Call Your Doctor

Call Immediately For:

Any fever ≥100.4°F (38°C)
Chills or shaking
Signs of infection anywhere
Persistent diarrhea
Burning with urination
Unusual bleeding or bruising
Exposure to contagious illness

Questions to Ask Your Doctor

What is my current ANC?
When will my counts be lowest?
Do I need growth factor support?
Should I take prophylactic antibiotics?
What temperature should trigger a call?
Can I continue working/school?
When can I resume normal activities?

Recovery Timeline

Factors Affecting Recovery

Type and dose of chemotherapy
Use of growth factors
Overall health status
Bone marrow reserve
Previous treatments
Nutritional status

Signs of Recovery

Rising ANC on blood tests
Increased energy
Resolution of mouth sores
Better appetite
Less susceptibility to infections

Returning to Normal Activities

Usually when ANC >1,000/μL
Gradually increase activities
Continue good hygiene practices
May still need precautions
Follow doctor's specific guidelines

Resources and Support

Emergency Resources

Keep oncologist's after-hours number handy
Know nearest emergency room location
Have transportation plan for emergencies
Consider medical alert bracelet

Support Services

Oncology nurse educators
Dietitian for neutropenic diet guidance
Social worker for practical support
Home health services if needed
Pharmacy consultation for medications

Educational Materials

Neutropenia wallet card
Temperature log sheets
Food safety guidelines
Hand hygiene posters
Symptom tracking apps

Tips for Caregivers

Learn about neutropenia and infection signs
Help maintain clean environment
Assist with temperature monitoring
Prepare safe meals
Limit visitors when counts are low
Stay home if you're sick
Get flu vaccine (not live vaccines)
Help track symptoms and medications
Know emergency procedures

References

NCCN Guidelines. Prevention and Treatment of Cancer-Related Infections. Version 1.2026.
ASCO Guidelines. Management of Febrile Neutropenia. J Clin Oncol. 2025.
CDC. Preventing Infections in Cancer Patients. Updated 2026.
Oncology Nursing Society. Chemotherapy-Induced Neutropenia Guidelines. 2025.
Crawford J, et al. Risk and timing of neutropenic events. J Natl Compr Canc Netw. 2025.

Last reviewed: January 24, 2026 | Medical Review: Dr. Rachel Thompson, MD