In the absence of randomized-controlled trials of iron therapy in patients with active infection, the harmful effects of iron therapy (IT) in this setting remains more theoretical than proven. ^1,2

Although many pathogens (eg, E. coli, Klebsiella, Salmonella, Yersinia, and Staphylococcus species) depend on iron for their growth^2,3, and iron overload states (eg, hemochromatosis) predispose to a variety of infections, studies evaluating the risk of infection with iron therapy have reported conflicting results.^1-4 A 2015 systematic review and meta-analysis of 103 trials comparing IV iron therapy  with several other approaches, including oral iron therapy or placebo, found no increased risk of infections with IV iron.⁵ In contrast, an earlier systematic review and meta-analysis involving fewer number of trials found an increased risk of infections with IV iron. ⁶

These varied results are perhaps not surprising since the effects of iron therapy on the risk of infection is likely to be context-specific, depending on the patient’s preexisting iron status, exposure to potential infections and co-infection and genetic background. ⁴ Of interest, mice with sepsis have worse outcomes when treated with IV iron.⁷

Perhaps the most prudent approach is to hold off on iron therapy until the active infection is controlled, unless the benefits of urgent iron therapy is thought to outweigh its theoretical harmful effects.

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References

1. Daoud E, Nakhla E, Sharma R. Is iron therapy for anemia harmful in the setting of infection? Clev Clin J Med 2011;78:168-70. http://www.mdedge.com/ccjm/article/95480/hematology/iron-therapy-anemia-harmful-setting-infection
2. Hain D, Braun M. IV iron: to give or to hold in the presence of infection in adults undergoing hemodialysis. Nephrology Nursing Journal 2015;42:279-83. https://www.ncbi.nlm.nih.gov/pubmed/26207288
3. Jonker FAM, van Hensbroek MB. Anaemia, iron deficiency and susceptibility of infections. J Infect 204;69:523-27. https://www.ncbi.nlm.nih.gov/pubmed/28397964
4. Drakesmith H, Prentice AM. Hepcidin and the iron-infection axis. Science 2012;338:768-72. https://www.ncbi.nlm.nih.gov/pubmed/23139325  
5. Avni T, Bieber A, Grossman A, et al. The safety of intravenous iron preparations: systematic review and meta-analysis. Mayo Clin Proc 2015;90:12-23. http://www.mayoclinicproceedings.org/article/S0025-6196(14)00883-0/pdf
6. Litton E, Xiao J, Ho KM. Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomized clinical trials. BMJ 2013;347:f4822. https://www.ncbi.nlm.nih.gov/pubmed/23950195
7. Javadi P, Buchman TG, Stromberg PE, et al. High dose exogenous iron following cecal ligation and puncture increases mortality rate in mice and is associated with an increase in gut epithelial and splenic apoptosis. Crit Care Med 2004;32:1178-1185. https://www.ncbi.nlm.nih.gov/pubmed/15190970