University of Virginia Health System

  NEUTROPENIA
Online Education Module

Learning Objectives
Neutropenia facts
Preventing infection
Identifying infection
Managing Infection
Glossary

  Learning objectives
After completing this learning module, you should be able to do the following:

1. Demonstrate an understanding of what neutropenia is, and why it occurs during treatment
2. Recall the steps to take to prevent infection
3. Recognize the signs and symptoms of infection
4. Respond appropriately if infection occurs

Infection is a problem that can be associated with brain tumor treatment.  At times, you may be at risk for infection from the side effects of treatment.  If signs of infection are ignored, you can become very ill. 

The body has many ways to protect you from infection.  Your skin, acid in the stomach, and coughing are some ways that the body protects itself.  As part of your immune system, your body makes white blood cells that destroy germs and bacteria after they enter the body.  One special type of white blood cell that kills germs and bacteria is called a neutrophil.  Neutrophils are made in the bone marrow, the spongy center of bones.  Chemotherapy and, sometimes, radiation treatment for brain tumor can cause the bone marrow to temporarily make fewer neutrophils than normal.  This condition is called neutropenia.  When your neutophils are low, you are said to be neutropenic, and may be at very high risk of developing infections.  Even common infections such as cold sores can be life threatening.  If you are neutropenic for only a few days, the risk of infection is small.  If your neutropenia lasts for a week or longer, your risk of infection can be very high.

When you are receiving treatment for a brain tumor, your doctor will order blood tests to count the number of neutrophils in your blood.  Your “counts” are likely to be at their lowest 10 to 14 days after your chemo treatment.  Your lowest neutrophil count after your treatment is called the nadir.  When you have fewer neutrophils to protect you from infection, you are more at risk for getting sick.  Usually within a few days after your nadir, your body will start making neutrophils again and your blood counts will go back up.  Generally, your blood counts will be back to normal about 3 to 4 weeks after chemotherapy.  Before you start your next chemo treatment, your physician will order blood tests again to be sure that you have enough neutrophils.

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• Keep your skin, mouth, and teeth clean. 
• WASH YOU HANDS OFTEN, always after using the bathroom.   Use warm water and soap or a waterless hand cleaner. 
• Keep your body very clean by bathing daily. 
• Brush your teeth twice daily to keep your mouth very clean.  Your doctor or nurse may also suggest that you rinse your mouth with a special cleansing solution.
• Protect your skin from cuts and scrapes.   Wear shoes.  Use an electric shaver instead of a razor.  Wear gloves when washing dishes or gardening. 
• Don’t scratch sores, cuts, or pimples. 
• Apply lotions to dry skin.
• Do not change cat litter or clean up excrement from animals yourself.   Ask others to clean up after pets – you could inhale germs. 

• Remove fresh flowers and live plants from the rooms where you stay.
• Eat a well-balanced diet and drink plenty of fluids. 
• Avoid uncooked fruits and vegetables.  Make sure all foods are cleaned and cooked well.  Ask others to peel all fruits and vegetables for you.

• Avoid constipation and straining to have a bowel movement by using a medication that softens the stool.  Drink 2 quarts of fluid a day.  Do not use laxatives or enemas unless approved by your doctor.
• Practice good bathroom habits.  Wipe yourself from front to back.  WASH YOUR HANDS after using the bathroom.
• Avoid large crowds or anyone with signs of infection, including people who have colds and other illnesses. 
• Avoid children who have had recent immunizations. 

• Check with your physician before you have dental work or immunizations.
•    When your counts are low, check you temperature daily, at the same time each day. 
• Don’t take medication for a fever unless prescribed by your doctor. 
• Call your doctor or nurse immediately if your fever is 100.3  F or above, generally feel unwell, or if you have other signs of infection.

Your physician may order a medication to help your bone marrow produce neutrophils and reduce your chance of developing an infection after treatment.  This medication is given by injection with a small needle, usually for 10 days, beginning 24 hours after your last chemotherapy treatment.  Most patients learn to give themselves the injection.

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Signs of infection include:

• Fever of 100.3  F or 38.5  C or above
• Sweating or chills
• Body aches, tiredness
• Cough with or without sputum production (phlegm)
• Flu-like symptoms
• Sore throat or mouth
• Diarrhea or loose stools
• Shortness of breath
• Difficulty or burning with urination
• Pain at the site of an IV
• Any area with redness or swelling
• Vaginal discharge or itching.

Fever is often the first sign of infection.   Because you may not have enough neutrophils to protect you from infection, don’t let a fever “run its course” as you may have done in the past with fevers that were not associated with chemotherapy or radiation treatment.  Don’t take medications to reduce the fever (such as aspirin, Tylenol (acetominophen), or Motrin (ibuprofen) before consulting your physician or nurse.  It is important for you to contact your physician or nurse right away if your temperature is 100.3  F or 38.5  C or above. 

It is important to know how to read a thermometer so that you can report a fever.   If you need help, ask your doctor or nurse to show you. 

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If your neutrophil count is too low or you are too sick, you may have to go to the hospital for intravenous (IV) antibiotics which will go directly into your bloodstream.  You may have to stay in a private room and your physicians, nurses, family, and friends may have to wear a mask when they visit you.  Your chemotherapy or radiation treatments may be delayed until your neutrophil counts show that you have enough neutrophils to protect you from infection.  Also, your chemotherapy dose may be lowered for future treatments to reduce the risk of your dropping your counts.

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  antibiotic – a drug used to treat a bacterial infection.  It may be given by mouth or through a vein (IV).

  blood cells – cells that make up the blood.  These cells are made in the bone marrow and include white blood cells, red blood cells, and platelets.

  blood count – the number of white blood cells, red blood cells, and platelets.

  bone marrow – the soft, spongy center of the bone where most of the blood cells are made before they enter the bloodstream.

chills – a feeling of being cold.  This often happens with fevers and may include shaking.

  constipation – occurs when unable to move bowels.  Narcotic pain medications, some chemotherapy drugs, antinausea medicines, and changes in diet can cause constipation.

  diarrhea – a change in stool consistency or form (bowels are loose, watery, or move more frequently).  May be accompanied by stomach cramps.

  fever – body temperature above 98.6  F.

  flu-like symptoms – includes muscle aches, fever, chills, shakes, weakness, headache, upset stomach, and diarrhea.  These may be a symptom or sign that you are ill or may be a side effect of chemotherapy drugs.

  immunization – a vaccine to protect us from disease (such as measles and chicken pox).  It is important for patients having chemotherapy to avoid children who have recently had immunizations because the vaccines are sometimes made from the actual bacteria.

  infection – occurs when a germ/bacteria enters the body and the person is unable to fight it off.  This can happen when a person is undergoing treatment for a brain tumor.  Signs of infection include fever, fatigue, chills, muscle aches.

  injection – giving medicine using a needle into the muscle, under the skin, or into the vein.

  intravenous – giving fluid or medicine into a vein through a needle.  Also called IV.

  nadir – period after chemotherapy treatment when blood counts are their lowest number.

  neutropenia – a condition when the number of neutrophils in the blood counts are low.

  neutropenic – a term used to describe a patient when the number of neutrophils in the blood counts are low.

  neutrophil – a type of white blood cell that kills bacteria.

platelet – a type of blood cell that helps the blood to clot.  Chemotherapy can lower platelet count.

red blood cell – the cells in the blood that carry oxygen to the organs and tissues and take carbon dioxide away.

  side effect – a symptom or a reaction that a person may have to brain tumor treatment.

  swelling – when fluid fills the spaces between the cells in parts of the body.  Swelling (also called edema) often occurs in the ankles and feet and may be a sign of infection.

  subcutaneous – under the skin.

  symptom – any change in the body’s function that would indicate disease or a reaction to treatment.

temperature – how hot the body gets.  Normal body temperature 98.6  F (Fahrenheit).

  thermometer – a tool used to check body temperature.  There are various types available.

  urination – emptying of urine from the bladder (“passing water”).

  vaginal discharge – fluid or mucus that leaks from the birth canal or vagina and may have a strong odor which is a sign of infection.

  white blood cell – cells in the blood that fight infection or germs.  Neutrophils are one type of white blood cell.

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References

Oncology Nursing Society, Neutrophil your one-in-a-million bodyguard guides you through neutropenia, ATAQ Community Education Project.

Yarbro, C.H., Frogge, M.H., and Goodman, M. (2004) Cancer Symptom Management, 3^rd edition, Sudbury, MA: Jones and Bartlett.

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