An Overview of the Neutropenic Diet

Controversial Approach for People Undergoing Chemotherapy

The neutropenic diet is the term used to describe food handling and selection practices that reduce the risk of bacterial infection from foods. Also known as the antimicrobial diet, it is typically used to prevent foodborne infections in people with severely weakened immune systems, such as those undergoing chemotherapy.

The diet is named after the defensive white blood cells, called neutrophils, that are the first responders to infection. Safe food handling, as well as the avoidance of certain foods, is believed to reduce the risk of infection in people with suppressed immune system.

Although a number of researchers believe that the restrictive nature of the neutropenic diet can lead to malnutrition, safe food handling is considered imperative to lowering the risk of chemotherapy-induced neutropenia. Whether the neutropenic diet is effective in preventing infection a subject of ongoing debate.

washing vegetables in sink
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Food Safety Guidelines

The prevention of bacterial transmission is the primary aim of the neutropenic diet. Oncologists insist that handwashing is the first-line defense against infection and the one that most people forgot. Food safety guidelines include:

  • Wash your hands frequently, before and after eating.
  • Avoid raw meats and eggs. Be sure to cook all the way.
  • Wash raw fruits and vegetables.
  • Avoid sharing food even with loved ones.
  • Do not share personal eating utensils.
  • Keep surfaces clean in the kitchen and dining room.

Food Storage and Preparation

Bacterial contamination will often occur during the preparation and storage of food. Recommendations for food preparation and storage include:

  • Keep hot foods hot (over 140° F)
  • Keep cold foods cold (under 40° F).
  • Eat defrosted foods right away. Do not refreeze.
  • Refrigerate foods at or below 40° F.
  • Do not thaw meat, seafood, or chicken at room temperature. Use the microwave or refrigerator instead.
  • After buying perishable foods, eat them within two hours. 
  • Eggs, cream, and mayonnaise-based foods should not be kept outside of the refrigerator for more than an hour.
  • Wash fruits and vegetables thoroughly with water before cutting or peeling. Wash lettuce leaves one at a time.
  • Do not use chemical-based rinses.
  • Rinse "prewashed" salads.
  • Avoid raw vegetable sprouts.
  • Toss food that smells funny or shows signs of spoilage.
  • Avoid pre-cut fruits and vegetables.
  • Wash the tops of canned foods with soap and water before opening.
  • Use a different utensil for eating and tasting foods while cooking. 
  • Throw away eggs with cracked shells.
  • Do not use the same cutting board or utensil for meat preparation as for vegetable and fruit preparation.
  • Use a meat thermometer to make sure meats are cooked to the proper temperature.

Some oncologists use the mnemonic "PICKY" to help people remember safe food practices. The letters in "PICKY" stand for:

  • Practice handwashing.
  • Inspect foods before you cook them.
  • Clean and scrub fruits and vegetables.
  • Keep all cooking surfaces clean.
  • Yucky, moldy food should be thrown away.

Dietary Restrictions

Depending on your oncologist and the center where you are undergoing chemotherapy, you may be advised to avoid certain foods. Foods typically avoided on the neutropenic diet include:

  • Raw meats and seafood (including sushi)
  • Raw nuts or fresh nut butter
  • Any foods that contain raw eggs (including Caesar salad dressing or homemade mayonnaise)
  • Soft and aged cheeses
  • Unpasteurized cheeses, milk, fruit juices, and vegetable juices
  • Bulk-bin cereals and grains
  • Cream-filled pastries that are not refrigerated
  • Raw honey or honeycomb
  • Water from a lake, spring, stream, or well
  • Vitamin-supplemented water
  • Refrigerated grocery store salsas

Current Research Findings

Oncologists are now putting more emphasis on safe food handling rather than the restriction of food. Chemotherapy already takes a huge toll on a person's body and appetite. Restrictions can actually worsen underlying nutritional deficiencies. Others question whether the diet actually helps.

A 2019 study in the American Journal of Clinical Oncology, which evaluated five randomized trials involving 388 people on chemotherapy, concluded that the use of a neutropenic diet was not associated with decreased risk of infection.

The same conclusions were reached in a 2018 study involving children on immune-suppressive chemotherapy. Instead of a neutropenic diet, approved food safety guidelines were recommended.

Other Dietary Challenges

In addition to safe food handling, people going through chemotherapy often have other challenges as well. Some of these include:

  • Mouth sores: Painful sores in the mouth are common, but choosing foods that are less likely to irritate the mouth can do wonders. Avoiding citrus foods, sharp foods (such as toast), and more is often advised.
  • Taste changes: Some chemotherapy drugs can make everything you eat taste metallic and has been coined metal mouth. Choosing foods with strong flavors and eating with plastic utensils can be helpful, among other changes.
  • Nausea and vomiting: Nausea and vomiting certainly interfere with eating, but there are now many options to control these symptoms. Talk to your oncologist.
  • Loss of appetite: Even if you simply don't feel like eating, there are tips that can help you get adequate nutrition.
  • Cancer fatigue: Fatigue is one of the most annoying symptoms of cancer treatment, and is not uncommonly the reason why people don't eat as healthily as they should. Make sure to ask for help with cooking, shopping, and cleaning up. Stock your pantry with easy-to-prepare foods such as canned soups, frozen entrees, frozen vegetables, and packaged puddings.

If you are concerned about food handling or foods to eat while on chemotherapy, talk to your oncologist and ask if seeing an oncology nutritionist might be helpful.

Preventive Tips

In addition to safe food practices, there are many ways in which you can reduce your risk of developing an infection during chemotherapy, especially when your white blood cell count is low.

While we often think about avoiding people who have a cough or runny nose, our pets can also be a source of infection. Birds, turtles, and reptiles such as lizards and snakes can carry the bacteria Salmonella, which can be life-threatening in people with severely suppressed immune systems.

Cat litter boxes are a common source of a protozoan infection called toxoplasmosis. During chemotherapy, you should assign the task of cleaning the litter box to a family member or friend.

When your immune system is suppressed, you would do best to avoid crowds or enclosed spaces such as an airplane, especially during cold and flu season.

People at risk of severe neutropenia are often prescribed Neulasta or Neupogen, the drug of which stimulates the production of neutrophils and reduces the risk of infection.

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