What is neutropenia?

When you are diagnosed with aplastic anaemia you may be neutropenic and at a greater risk of infection from bacteria or fungus in foods. Neutropenia means that neutrophils, which are one type of white cell, are at a low level and you are therefore at greater risk of food poisoning. It may be necessary for you to follow a ‘neutropenic’ or ‘clean’ diet.

Levels of neutropenia

Patients with a neutrophil count of between 0.5 and 2.0 are considered to be neutropenic. If the neutrophil count is lower than 1.0, your doctor may recommend that you follow a neutropenic or clean diet.

Following a clean diet

The advice in this fact sheet will help you to avoid infection, while still having as varied a diet as possible. It also gives general advice on safe food handling and storage for patients at risk of neutropenia. Not everyone will be advised to follow a neutropenic diet so please follow the guidance from your clinical team.

General advice - Shopping

• Avoid buying food with damaged or broken packaging
• Do not buy food from fridges or freezers that are overloaded as the food may not be cold enough
• Buy chilled and frozen foods last and get them home as quickly as possible. If it is not possible to get food home immediately, an insulated container or cool bag can help to keep food at the correct temperature
• Buy foods in small, individual packets. Avoid large packets that will be open longer and increase the chance of bacteria contaminating them
• Always check ‘best before’ or ‘use by’ dates on packaging
• Avoid shops where raw and cooked meats are stored in the same fridge or in a deli counter without a separating wall. Where possible buy pre-packed deli items.

Storing food

• Keep your fridge between 0° and 5°
• Keep your freezer below -18°. Always ensure that food is still frozen solid when it is removed from the freezer
• Store cooked food at the top of the fridge
• Raw or defrosting meat or fish should be stored at the bottom of the fridge in a covered container to prevent dripping or leaking into the fridge
• Do not overload your fridge or freezer as this will increase the temperature
• Always store eggs in the fridge
• Use and store food following the manufacturer’s instructions and within ‘best before’ or ‘use by’ dates
• Never refreeze thawed food.

Food preparation

• Always wash your hands with warm water and soap before preparing food
• Always wash your hands after going to the toilet, sneezing and after touching pets, hair, dirty washing, rubbish, ready- made or raw food
• Use a separate towel or kitchen paper to dry your hands. Do not use a tea towel
• Cover any cuts and grazes with a waterproof plaster
• Keep pets away from work surfaces, food and your dishes
• Ensure any cloths or sponges are regularly bleached, disinfected or changed
• Avoid cross- contamination of food by changing or washing chopping boards and utensils between raw and cooked food. Ideally you should have three boards: one for raw meat, one for cooked meat and one for other foods.
• Avoid reheating rice or takeaway food, as harmful bacteria can survive the heating process
• Always cover food to prevent contamination

Kitchen hygiene

• Disinfect work surfaces regularly
• Wash can tops before opening them
• Wash fruit and vegetables before eating
• Clean tap spouts regularly
• Wash the roof and the inside of your microwave regularly.

Cooking

• Defrost food in the fridge, not at room temperature
• Cook all food thoroughly and ensure it is piping hot all the way through. Ensure that food reaches a temperature of 70°c or more before serving
• Cook meat until the juices are clear
• Pre-heat the oven to ensure food is cooked at the recommended temperature
• Always follow manufacturer’s guidelines and do not shorten cooking times.

Reheating food

• Eat rice as soon as it is cooked and do not reheat cooked rice as harmful bacteria can survive the heating process
• Microwave cookers can be used for defrosting and for heating prepared foods according to the manufacturers instructions
• For home-cooked foods, cool food at room temperature within an hour after cooking and then refrigerate or freeze
• Do not reheat food more than once
• Do not reheat takeaway food
• Do not put hot food in your fridge as this will increase the temperature of all food in the fridge making it unsafe to eat
• Cover food and allow it to cool to room temperature before putting it in the fridge.

Eating out

• Ensure food is piping hot when served and cooked all the way through
• Choose freshly prepared foods from reputable outlets. Avoid salad bars, street vendors, market stalls, buffets, all-you- can-eat restaurants and ice cream vans
• Avoid foods which have been left out on display such as doner kebab meat
• Check restaurant hygiene ratings at ratings.food.gov.uk. To keep yourself safe, make sure that the restaurant or takeaway has a food hygiene rating of 5.
• Talk to your doctor or healthcare team about eating out in restaurants or visiting crowded places

Food Safety Advice during Neutropenia (neutrophil count is below 1.0 x 10^9/L)

The following is a list of foods which are considered to be ‘high risk’ and which should be avoided by neutropenic patients. We have listed some suitable alternatives for you to try instead. Please check with your hospital for their policy regarding food brought in by visitors.

	Foods to be avoided	Safer alternatives
Meat and poultry	Raw or undercooked meat and poultry, e.g. meat which is still pink – rare steak Smoked or cured meat, e.g. salami or Parma ham Unpasteurised paté Rotisserie chicken Meat from a barbeque	Well-cooked meat and poultry. Juices should run clear and no pink showing. Smoked or cured meat is cooked and piping hot Cooked, cold, sliced meats from a packet eaten as per manufacturer advice Tinned or jar meat or paste
Fish and shellfish	Avoid smoked salmon unless eaten directly from a freshly opened packet Raw or lightly cooked shellfish (lifelong avoidance) Sushi made with raw fish	Vacuum packed fish eaten straight from a new packet. Well-cooked shellfish, e.g. prawn curry Well-cooked fresh, frozen or tinned fish
Milk and yoghurt	Unpasteurised milk or yoghurt (can be found in some markets and from farms) Probiotic yogurts and probiotic supplements such as Yakult© or Actimel®	Pasteurised milk and yoghurt – those found in supermarkets will be pasteurised Includes live, Greek and fruit yoghurts
Cheese	Soft, ripened cheeses such as brie, camembert, goat cheese and blue veined cheese such as blue stilton Soft goats and sheep cheeses Cheese made with unpasteurised or raw milk	Pasteurised cheeses – check labels (most hard cheeses will be fine) Processed cheese, cream cheese, kraft cheese, cottage cheese White stilton
Eggs	Raw or undercooked eggs Raw egg products eg homemade mayonnaise, homemade ice cream, mousse, egg-nog, hollandaise sauce	Shop bought mayonnaise and other products made with pasteurised egg
Fruit and Vegetables	Unwashed fruit, vegetables and salad Salad from salad bars Damaged or overripe fruit or vegetables Unpasteurised or freshly squeezed fruit or vegetable juice or smoothies.	Fresh fruit and vegetables should be washed well Tinned fruit. Freshly prepared washed salad
Ice cream	Ice cream sold from mobile vans or soft-serve machines such as Mr Whippy©/McFlurry© Homemade ice cream Milkshakes from ice cream makers such as McDonalds or Burger King	Hard or individually wrapped ice creams Fresh milkshakes
Other	Unpasteurised or ‘fresh farm’ honey or honeycomb Stuffed vine leaves Fresh nuts and nuts in shells Deli counter products including olives, hummus	Pasteurised or heat-treated honey Golden syrup or Jam Cooked nuts, nuts in a can, nut butters Pre packed hummus, olives

This information has been provided by the Haematology Sub Group of the British Dietetic Association’s Oncology Specialist Group. It is a guide and neither The AAT nor the BDA can advise on individual cases. You should therefore continue to be advised by your clinical team.

General advice

• If you have a freezer, try to prepare food in advance when you feel like cooking and store it for when you are not feeling so well
• Avoid filling yourself up with large servings of vegetables, salads, water and fizzy drinks. They provide bulk but little nourishment
• Tempt your appetite by making foods look attractive - use small portions on a small plate and try adding garnishes such as lemon or parsley
• Sometimes the smell of food will be appetising while at other times it may put you off. If this happens, try to keep away from the kitchen while food is being prepared, or eat cold foods which often have less smell
• If you continue to be concerned about your diet and weight loss, there is a wide range of nutritional supplements available on prescription. They can be used to supplement your intake and help to maintain your weight. If you feel you would benefit from using these products, ask your dietitian who will be able to advise you.

Recipes

Looking for inspiration? Check out the recipes submitted by our community in our recipe competition!

Booklet

You can order this information as a printed booklet from our shop, or download it as a pdf here

Clean Diet Booklet