Should oral iron supplementation be stopped in patients with sepsis?

Oral Iron Supplementation Should Be Stopped in Patients with Sepsis

Oral iron supplementation should be discontinued in patients with sepsis due to increased risk of bacterial growth and potential worsening of infection outcomes. 1

Rationale for Stopping Oral Iron in Sepsis

Iron and Infection Risk

• Iron is an essential nutrient for both humans and microbes, including bacteria 2
• During sepsis, the body naturally sequesters iron intracellularly to limit its availability to pathogens 3
• Supplemental iron therapy during acute infection could counteract this protective mechanism by:
  • Increasing iron availability for invading microbes
  • Potentially enhancing bacterial growth
  • Contributing to oxidative stress 2

Evidence from Guidelines

• The Kidney International Supplements explicitly recommends using intravenous iron "with caution, if at all, in patients with active infection" 1
• The same guideline specifically lists a research recommendation to determine "whether iron supplementation should be continued in patients with potential infections" 1
• Experimental studies in animals suggest that intravenous iron is harmful in the presence of severe infection 1

Clinical Considerations

• High transferrin saturation and elevated serum iron levels are associated with reduced survival in septic patients 4
• A 2023 Mendelian randomization study found that increases in iron biomarkers increase the odds of sepsis 5
• Iron restriction has been hypothesized as a potential therapeutic approach in sepsis 6

When to Resume Iron Supplementation

Iron therapy should be resumed only after:

1. Complete resolution of sepsis
2. Hemodynamic stabilization
3. Resolution of the acute inflammatory response

The recovery phase of critical illness is the appropriate time to address persistent iron deficiency, as continued deficiency can lead to:

• Cognitive dysfunction
• Fatigue
• Cardiopulmonary dysfunction 2

Monitoring Parameters Before Resuming Iron

Before restarting iron therapy, assess:

• Complete blood count
• Serum ferritin (may be falsely elevated during inflammation)
• Transferrin saturation
• Clinical signs of resolved infection (normalization of vital signs, WBC count, and inflammatory markers)

Alternative Approaches During Sepsis

For patients with severe anemia requiring intervention during sepsis:

• Consider red blood cell transfusion for hemodynamically significant anemia
• Focus on treating the underlying sepsis as the first step in addressing anemia 1
• Early and progressive enteral nutrition should be used in septic patients after hemodynamic stabilization 1

Conclusion

Withholding oral iron supplementation during sepsis aligns with the body's natural iron-withholding defense mechanism against pathogens. The potential risks of providing additional iron during active infection outweigh the benefits, and iron therapy should be resumed only after complete resolution of sepsis and stabilization of the patient's condition.