IV Iron Usage in Pneumonia
What are your thoughts on use of intravenous (IV) iron in a patient with, for instance, pneumonia vs use in a patient with bacteremia related to something like endocarditis or an infected vascular graft?

Gary A. Kell, MD

I would not recommend the administration of IV iron in pneumonia. It is possible that administration of IV iron may exacerbate infections. There is experimental evidence (animal) that administration of metals including iron may induce pulmonary inflammation. Iron therapy has been associated with acute exacerbations of infection, in particular malaria, but also Pseudomonas aeruginosa and Legionella (where iron acquisition functions of L pneumophila play key roles in pathogenesis). With regard to iron-overloaded patients with beta-thalassemia, infections are the most common cause of mortality, particularly pneumonia as a result of Klebsiella pneumoniae.

Of interest, nontransferrin-bound iron is increased in the lower respiratory tracts of patients suffering from Pneumocystis carinii pneumonia? and this finding would lend experimental support to the use of iron-chelating agents in this disease.

With regard to antibiotic therapy, moxifloxacin attains good penetration into respiratory tissues and fluids, although its bioavailability is substantially reduced by coadministration with an iron preparation.

However, iron deficiency is associated with reversible abnormalities of immune function. In a perioperative study, incidence of pneumonia increased from 2.6% to 5% with increasing degree of anemia. It is important to note that in dialysis patients requiring IV replacement, there does not seem to be a significant association between IV iron administration and the risk of bacteremia, unless given high-frequency, high-dose IV iron.

Occult infection of old nonfunctioning arteriovenous grafts is a common cause of erythropoietin resistance and persistent anemia among hemodialysis patients. Resection is associated with resolution.

Iron replacement should also be used with caution in patients with bacteremia, ensuring adequate and aggressive therapy of the underlying infection and close monitoring of response and requirements for the supplementation.