EGFR is a poor estimate of renal function in intensive care

Appendix I where ideal body weight (IBW) is calculated as:

Formulae used in manuscript IBW (male) = 50 kg + 0.9 kg for each cm > 150 cm in
height
Measured creatinine clearance (mL/min)
IBW (female) = 45 kg + 0.9 kg for each cm > 150 cm in
urine creatinine concentration × volume
= height
plasma creatinine con
ncentration

Cockcroft Gault (mL/min) ‘186’ MDRD (eGFR) (mL/min/1.73 m2)

Creatinine clearance (mL /min) = 186 ¥ (Scr/88.4)-1.154 ¥ age-0.203 ¥ 0.742 if female ¥ 1.21
[140 − age (years)] × weight (kg) if African American
= (×0.85 if female)
0.814 × plasma creatinine (µmol / L)
‘Unadjusted’ eGFR (mL/min)
Cockroft Gault adjusted for ideal body weight
(IBW)45,46 = eGFR ¥ BSA/1.73

Creatinine clearance (mL /min) Calculation of body surface area

[140 − age (years) × IBW (kg)]
=
0.814 × plasma creatinine (µmol / L) BSA (cm2) = 71.84 ¥ weight (kg)0.425 ¥ height (cm)0.725

Necrotizing fasciitis: review of 82 cases in South Auckland

M. Nisbet,1 G. Ansell,2 S. Lang,1 S. Taylor,1 P. Dzendrowskyj2 and D. Holland1
1
Infectious Diseases Department and 2Department of Intensive Care, Middlemore Hospital, Auckland, New Zealand

Key words Abstract

necrotizing fasciitis, group A streptococcus,
streptococcal infection, gout.
Correspondence
Mitzi Nisbet, Infectious Diseases Department,
Middlemore Hospital, Private Bag 93311,
Otahuhu, Auckland, New Zealand.
Email: mitzin@adhb.govt.nz
Received 8 July 2009; accepted 17 November
2009.
doi:10.1111/j.1445-5994.2009.02137.x
Background: Early recognition of necrotizing fasciitis (NF) can be difficult, but is
important as infections progress rapidly and have significant mortality. The aim of this
study of patients with NF was to determine the clinical characteristics at presentation,
causative pathogens and subsequent clinical outcome.
Methods: We retrospectively reviewed consecutive patients with NF presenting to
Middlemore Hospital from January 2000 to June 2006.
Results: Eighty-two patients were evaluated: 56% male, mean age 54.9 years (standard
deviation 18.5), 40% Pacific Islanders. The site of infection was the lower limb in 46
(56%) patients, upper limb in 12 (15%) patients and perineum in 13 (16%) patients.
Twenty-two (27%) patients were taking non-steroidal anti-inflammatory drugs, 29
(35%) had diabetes mellitus, 25 (30%) had gout and 17 (21%) had congestive heart
failure. Forty-nine (60%) patients had a surgical procedure within 24 h of admission.
Streptococcus pyogenes was isolated from tissue or blood cultures in 33 (40%) patients and
26 (32%) patients had polymicrobial infection. Twenty-five (30%) patients died, 17
(68%) within 72 h of admission. Independent predictors of mortality include congestive
heart failure (P = 0.033) and a history of gout (P = 0.037).
Conclusion: NF remains an important disease in our community with significant
morbidity and mortality. Pacific Islanders were disproportionately represented. Early
diagnosis of NF can be difficult and requires a high index of suspicion in all patients
presenting with cellulitis or unexplained sepsis. Congestive heart failure and gout are
independent predictors of mortality and patients with these conditions and sepsis need
early assessment with more aggressive hospital triaging.

© 2011 The Authors

Internal Medicine Journal © 2011 Royal Australasian College of Physicians 543
Nisbet et al.
Introduction
Necrotizing fasciitis (NF) is a severe infection involving the
subcutaneous soft tissues and fascial planes, and often the
deep fascial layers.1,2 Treatment involves both appropriate
antibiotic therapy and also early aggressive surgical debri-
dement. A delay in diagnosis and commencement of
appropriate treatment has been shown to result in
increased mortality as the clinical course may be rapidly
progressive.3,4 NF can be very difficult to diagnose early in
the course of the illness as initial clinical findings may be
minimal.4 Fournier’s gangrene is NF involving the peria-
nal area and is due to enteric organisms penetrating the
gastrointestinal or urethral mucosa. These infections
spread rapidly on to the anterior abdominal wall, into the
gluteal muscles and in males onto the scrotum and penis.2
Two main clinical forms of NF occur known as type I
and type II. Type I is due to polymicrobial infection
usually with aerobic and anaerobic bacteria.5 It occurs
particularly after surgical procedures and in patients with
diabetes mellitus and peripheral vascular disease. Type II
is usually caused by group A streptococcus or less
commonly Staphylococcus aureus (including methicillin-
resistant S. aureus (MRSA)) or group G streptococcus.6,7
Numerous retrospective case series have been
described predominantly in the surgical literature.6,8–10
There is considerable variation in case definition and
inclusion criteria with mortality rates ranging from 17%
to 49%.4,11–14 Conditions that have been associated with
NF include intravenous drug use, diabetes mellitus,
obesity, trauma and immunosuppression.1,6,7,9,15
In South Auckland, New Zealand, NF is an important
cause of infection-related morbidity, especially in Maori
and Pacific Islanders with a high overall mortality rate of
29%.15 Tiu et al. previously showed that in our commu-
nity a delay in diagnosis and diabetes mellitus was asso-
ciated with increased mortality.15
The aims of this study of patients presenting to Middle-
more Hospital with NF were to determine their clinical
characteristics, sites of infection, causative pathogens,
subsequent clinical management and outcome and to
review potentially modifiable risk factors for mortality.
Methods
Patient selection
A retrospective study of consecutive patients presenting
to Middlemore Hospital with NF, from January 2000 to
Funding: None.
Conflict of interest: None.
544
July 2006, was undertaken. Middlemore Hospital is a
major metropolitan hospital in Auckland serving a popu-
lation of over 460 000. Patients with NF or Fournier’s
gangrene were identified from a computer-generated
search from hospital-wide clinical coding discharge diag-
noses. A review of each patient’s notes was undertaken
and data were collected on patient demographics, clinical
characteristics, sites of infection, causative pathogens,
comorbidities, clinical management and outcome. The
study was given expedited ethics approval.
The Australasian triage score at presentation was
recorded. The Australasian triage score is a scale for rating
clinical urgency and is designed for use in hospital-based
emergency services.16 Patients receive a triage score of 1
through to 5 based on the urgency of need for medical
assessment. A patient assessed with an Australian triage
score of 1 should be seen immediately, whereas a patient
with a score of 4 should have a maximum waiting time of
60 min and a patient with a score of 5 should be seen
within 120 min.
Inclusion criteria
NF was defined as infection involving the fascia and
subcutaneous tissue as confirmed at surgical debridement
or in patients where surgery was not performed, consis-
tent clinical findings including skin necrosis and systemic
signs of sepsis.
All patients were aged ⱖ15 years. Patients were
excluded if they were transferred from another hospital
where they had been initially assessed and treatment
commenced.
Statistical methods
Results are presented as mean (standard deviation, SD)
or frequencies and percentages. Continuous variables
were compared between survivors and non-survivors
using an unpaired t-test and categorical variables with a
chi-squared test, except where 25% of the cells had
expected counts of <5, in which case the Fisher’s exact
test was used. P-values of <0.05 were regarded as being
statistically significant. Significant factors in the univari-
ate analysis were entered into a multivariable logistic
regression model with death as an outcome. Stepwise
selection on the basis of model fit (Akaike’s information
criterion) was performed to create the final model. No
interaction terms were identified.
Results
One hundred and twenty-three patients were identified
with a diagnosis of NF or Fournier’s gangrene. Eighty-
© 2011 The Authors
Internal Medicine Journal © 2011 Royal Australasian College of Physicians
 Necrotizing fasciitis

Table 1 Patient characteristics at initial assessment Twenty-two (27%) patients reported non-steroidal
Patients with necrotizing anti-inflammatory drug (NSAID) use, most commonly
fasciitis (n = 82) diclofenac (12 patients, 15%). Forty-one per cent of the
n (%) group known to be on NSAIDs at admission were febrile
Male 44 (54)
compared with 50% of the patients that were not known
Ethnicity to be on NSAIDs, but this was not statistically significant
Pacific Islander 33 (40) (P = 0.47). Twenty-five (30%) patients had a previous
European 32 (39) diagnosis of gout. Twenty-nine (35%) had known dia-
Maori 15 (18) betes mellitus, and 18 (62%) of those were on medical
Clinical features treatment, including nine (31%) patients who were on
Pain 73 (89)
regular insulin treatment. No intravenous drug users
Swelling 71 (87)
Blue or purple skin discolouration 36 (44)
were identified in this cohort.
Pyrexia (>37.5°C) 36 (44) The mean white blood cell count at presentation was
Ulceration 31 (38) 20.5 ¥ 109/L (SD 11.6) and 58 (71%) had a glucose of
Blistering 18 (22) >6.0 mmol/L at admission. Renal impairment at presen-
Rigours 10 (12) tation was common with 51 (62%) patients having an
Comorbidities: elevated creatinine (>0.12 mmol/L).
Diabetes mellitus 29 (35)
A number of patients spoke only limited English and
Gout 25 (30)
Chronic respiratory disease 18 (22)
14 patients (17%) required an interpreter. Ten (12%)
Congestive heart failure 17 (21) patients did not have a recorded telephone number and
Obesity 16 (20) six (7%) patients lived alone.
Smoker 14 (17)
Chronic renal impairment 11 (13)
Ischaemic heart disease 10 (12) Microbiology
Sixty-one (74%) patients had blood cultures completed
within 72 h of admission and only 15 (18%) of these
two patients fulfilled inclusion criteria and were evalu- grew a pathogen (Table 2). None of these patients had
ated. Of the 41 patients excluded: 28 were transferred received antibiotics prior to blood cultures being
from another institution (Middlemore Hospital is a ter- obtained. Streptococcus pyogenes was isolated from tissue or
tiary plastics referral centre) and 13 did not fulfil our blood cultures in 33 (40%) patients, and S. aureus
definition of NF and likely had only superficial infection. (including MRSA) was isolated in seven (9%) patients;
The number of patients presenting with NF each year 26 (32%) patients had polymicrobial infection, although
ranged from five to 21 patients. these were not reflected in the blood cultures. Five (6%)
patients had MRSA isolated; one from blood cultures and
Initial assessment four patients from tissue specimens. Four of the MRSA
isolates were only resistant to b-lactam antibiotics con-
The mean age at presentation was 54.9 years (SD 18.5). sistent with community-acquired MRSA. Group G strep-
Most patients presented with symptoms of pain and tococcus was isolated in four patients, including two
swelling. Patient demographics, presenting symptoms patients with positive blood cultures. The bacterial cause
and comorbidities are outlined in Table 1. Forty-four was unknown in eight (10%) patients, five of whom died
(54%) patients were initially assessed by a general prac-
titioner prior to admission, but only two (5%) referral
letters included NF as a possible diagnosis. Fifteen (18%)
patients received antibiotics prior to admission and one of Table 2 Isolates from blood cultures completed within 72 h of admission
these patients was on community intravenous antibiotic Blood culture isolate Number of isolates (%)
treatment. Twenty-six (32%) patients had an initial (n = 15)
Australasian triage score of 4 or 5 at presentation.16 Streptococcus pyogenes 7 (47)
The site of infection was the lower limb in 46 (56%) Group G streptococcus 2 (13)
patients, upper limb in 12 (15%) patients, perineum in Staphylococcus aureus 2 (13)
13 (16%), abdomen in 6 (7%), thorax in 4 (5%) and face Serratia marcescens 1 (7)
in 1 patient. Thirty-four (41%) patients reported either Clostridium spp. 1 (7)
a surgical procedure or trauma immediately prior to Fusobacterium spp. 1 (7)
Vibrio vulnificus 1 (7)
presentation.

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Internal Medicine Journal © 2011 Royal Australasian College of Physicians 545
Nisbet et al.

Table 3 Associations with mortality

Patient characteristics Survivors (n = 57) Non-survivors (n = 25) P-value

Mean (SD) or n (%) Mean (SD) or n (%)

Age 50.6 (17.7) 64.7 (16.9) 0.001

Sex, male 31 (54) 15 (60) 0.82
Chronic renal impairment 4 (7%) 7 (30%) 0.017
Ischaemic heart disease 3 (5%) 7 (28%) 0.011
Congestive cardiac failure 5 (9%) 12 (48%) <0.001
Gout 12 (21%) 13 (52%) 0.011
Surgical procedure within 24 h of admission 41 (72%) 8 (32%) 0.002
Ethnicity, non-European 36 (63) 15 (60) 0.98
Diabetes mellitus 17 (30) 12 (48) 0.18
Streptococcus pyogenes isolated 39 (72) 9 (45) 0.06
Infection of upper or lower limb 37 (65) 20 (80) 0.27
On non-steroidal anti-inlammatory drugs 14 (25) 8 (32) 0.67
Current smoker 13 (24) 1 (4) 0.10

SD, standard deviation.

shortly after admission. Of these five only one had
surgery.
Treatment and follow up
Forty-nine (60%) patients had a surgical procedure
within 24 h of admission. The mean length of acute hos-
pital stay was 24.5 days (SD 24.6, range 1–109) and 43
(52%) patients were admitted to intensive care. Only
seven (9%) patients required amputation of a limb, but
most patients required extensive debridement. The
median number of surgical procedures per patient was
two (range 0–15).
A wide range of antibiotic combinations was used as
initial therapy. Nineteen (23%) patients received clinda-
mycin and ciprofloxacin ⫾ a beta-lactam as first-line
therapy. Only three (4%) patients received a carbapenem
as part of their initial medical treatment. Fifty-six (68%)
patients were treated with clindamycin in combination
with other antimicrobials.
Twenty-five (30%) patients died. The median time
from admission to death was 2 days (range 0–63). Seven-
teen (64%) patients died within 72 h of admission. Ten
(12%) deaths occurred in patients who did not have
surgical debridement. Seven (9%) of these patients had
significant comorbidities precluding surgical intervention,
including two (2%) patients with severe chronic obstruc-
tive pulmonary disease, two (2%) with severe congestive
cardiac failure, two (2%) with advanced dementia and
one (1%) with advanced myelofibrosis. Two of the
patients who died had severe irreversible septic shock and
died shortly after admission to hospital. One patient
declined surgery and died 4 days after admission.
Eight of 49 (16%) patients who had a surgical proce-
dure within 24 h of admission died. Twenty-three (28%)
patients had an initial surgical procedure more than 24 h
after admission. Six of 14 (43%) patients who had sur-
gical intervention between 24 and 48 h after admission
died. Triage scores were recorded in 18/23 (78%) of the
patients who had surgery delayed by 24 h or more, and
all patients had an admission Australasian triage score of
3 or 4 except for one patient whose score was 2.
Age, chronic renal impairment, ischaemic heart
disease, congestive cardiac failure, gout and late surgical
intervention were all associated with mortality (Table 3).
Independent predictors of mortality on stepwise multi-
variable logistic regression were congestive heart failure
(odds ratio (OR) 4.84; 95% confidence interval (CI) 1.13,
20.63; P = 0.033) and gout (OR 4.08; 95% CI 1.09, 15.33;
P = 0.037). None of the patients with MRSA isolated from
cultures died.
Discussion
NF remains an important cause of infection-related mor-
bidity and mortality in our community. Pacific Islanders
are disproportionately represented, making up 40% of
our cohort compared with only 22% of all admissions to
Middlemore Hospital for the duration of the study. The
2001 New Zealand census data identified that 19% of the
residents of the Middlemore Hospital area were Pacific
Islanders.
Pacific Islanders do not have an overall increased inci-
dence of admission for cellulitis to Middlemore Hospital
(M Nisbet and D Holland, unpublished data, 2006), but
we found that they had an increased incidence of severe
infection, although this did not translate into an increased
risk of death. There may be a number of confounding
factors, such as delayed presentation, impaired commu-
nication (including need for interpreters and no ready

© 2011 The Authors

546 Internal Medicine Journal © 2011 Royal Australasian College of Physicians
 Necrotizing fasciitis

access to a telephone) and comorbidities, such as diabetes
mellitus and renal impairment. Diabetes mellitus (both
previously diagnosed and undiagnosed disease) is likely to
be an important contributing risk factor in this popula-
tion. The New Zealand Health Survey (2002/2003) found
that 10.1% of Pacific Islanders in New Zealand had dia-
betes compared with only 2.9% of the European popula-
tion.17 Compared with Europeans aged >40 years, the
prevalence of undiagnosed diabetes is more than fourfold
among Pacific Islanders.18
Many patients presented with classical symptoms of
pain and swelling, but only 60% of patients had a surgical
procedure within 24 h of admission. Twelve per cent
either declined surgery or were not considered as surgical
candidates. This suggests that the diagnosis of NF was
uncertain at admission for a significant number of
patients resulting in delayed intervention and increased
mortality. Fewer than 50% were pyrexial at admission,
which may have been influenced by prior treatment with
NSAIDs. A lower percentage of patients on NSAIDs at
admission were afebrile when compared with patients
that were not on NSAIDs. NSAID use was identified in
27% of our cohort, perhaps an underestimate in this
retrospective review. Over 30% of patients had a triage
score of 4 or 5, suggesting haemodynamic stability at
presentation. These findings emphasize the importance
of considering NF even though clinical signs may be
minimal, and also emphasize that overt shock and insta-
bility are often late and frequently a preterminal state.
MRSA was isolated from five patients and all of these
received early treatment with clindamycin to which their
strains were susceptible. The possibility of MRSA must be
considered when deciding appropriate antibiotic therapy
prior to culture availability, especially in communities
where MRSA is relatively common.
NF complicating gout has been previously observed,
and more recently Yu et al. described 15 patients with
gout and NF.19 In that series three patients (20%) died, all
from septic shock.19 Gout is a common and difficult
problem in South Auckland, but its link to NF in our
community has not been studied previously.20 Although
gout was an independent predictor of mortality there
may be a number of confounding factors, including undi-
agnosed diabetes, use of NSAIDs, which may have been
underreported and delayed presentation because of
incorrect attribution of symptoms to gout. The impor-
tance of gout as a marker for mortality in this cohort
warrants further awareness and investigation.
Conclusion
NF remains a difficult condition to diagnose and has a
high mortality in our community. Early diagnosis of NF
can be difficult and requires a high index of suspicion in
all patients presenting with cellulitis or unexplained
sepsis. Congestive heart failure and gout were indepen-
dent predictors of mortality in our cohort, and patients
with these conditions and sepsis especially need early
assessment, aggressive triaging and rapid intervention.
Acknowledgements
The authors gratefully acknowledge the assistance of
Katrina Poppe (Biostatistician, UniServices, University of
Auckland), Paula Wallis, Karen Gunson and Rebecca
Findlay (Outpatient Intravenous Antibiotic Service,
Middlemore Hospital), Stephen Park and Andrea Rigby
(Clinical Coding Department, Middlemore Hospital) and
the Department of Surgery (Middlemore Hospital).

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A rapid infusion protocol is safe for total dose iron

polymaltose: time for change
M. Garg,1 G. Morrison,1 A. Friedman,2 A. Lau,3 D. Lau3 and P. R. Gibson1,4
1
Department of Gastroenterology and Hepatology, Eastern Health and 2Department of Gastroenterology, Frankston Hospital and 3Pharmacy
Directorate, Eastern Health and 4Monash University Department of Medicine, Eastern Health Clinical School, Melbourne, Victoria, Australia

Key words Abstract

iron infusion, iron polymaltose, iron deficiency,
rapid iron infusion.
Correspondence
Peter Gibson, Department of Medicine, Box Hill
Hospital, Box Hill, Vic. 3128, Australia.
Email: peter.gibson@med.monash.edu.au
Received 3 April 2010; accepted 25 July 2010.
doi:10.1111/j.1445-5994.2010.02356.x
Background: Intravenous correction of iron deficiency by total dose iron polymaltose
is inexpensive and safe, but current protocols entail prolonged administration over more
than 4 h. This results in reduced patient acceptance, and hospital resource strain. We
aimed to assess prospectively the safety of a rapid intravenous protocol and compare this
with historical controls.
Methods: Consecutive patients in whom intravenous iron replacement was indicated
were invited to have up to 1.5 g iron polymaltose by a 58-min infusion protocol after an
initial 15-min test dose without pre-medication. Infusion-related adverse events (AE)
and delayed AE over the ensuing 5 days were also prospectively documented and graded
as mild, moderate or severe.
Results: One hundred patients, 63 female, mean age 54 (range 18–85) years were
studied. Thirty-four infusion-related AE to iron polymaltose occurred in a total of 24
patients – 25 mild, 8 moderate and 1 severe; higher than previously reported for a slow
protocol iron infusion. Thirty-one delayed AE occurred in 26 patients – 26 mild, 3
moderate and 2 severe; similar to previously reported. All but five patients reported they
would prefer iron replacement through the rapid protocol again. The presence of
inflammatory bowel disease (IBD) predicted infusion-related reactions (54% vs 14%
without IBD, P < 0.001) and the serum C-reactive protein was higher in those with
reactions (P = 0.043).
Conclusion: Iron polymaltose can be successfully administered using a rapid total dose
infusion protocol and was well accepted by patients. It offers significant cost, resource
utilization and time benefits for the patient and hospital system.

© 2011 The Authors

548 Internal Medicine Journal © 2011 Royal Australasian College of Physicians