Proton Pump Inhibitors and Corticosteroids as Synergistic Risk Factors for Candida Esophagitis

Introduction: Inhaled & systemic steroid use is one of the well-documented risks predisposing to the development of Candida esophagitis (CE). However, the role of gastric acid suppression-as another predisposing factor- remains controversial. Methods: We conducted a retrospective case-control study of 420 patients consisting of 84 cases of CE and 336 matched controls. Our cohort was gathered from subjects evaluated from January 1, 2001 to January 31, 2012. The diagnosis of CE was based on endoscopic and / or histological criteria. Results: On univariate analysis, Proton Pump Inhibitors (PPIs) were associated with a higher risk of CE (OR = 2.14; 95 % CI: 1.30 to 3.54); steroid use also increased the risk of CE (OR = 3.55; 95 % CI: 2.10 to 6.00). Furthermore, concurrent use of PPIs & steroids substantially raised this risk (OR = 13.8; 95 % CI 5.07 to 37.5), suggesting a synergistic effect. When adjusted for covariates (cancer, chemotherapy/radiation, antibiotic use, hypothyroidism, anemia, chronic liver disease & diabetes), anemia was found to decrease the odds ratio for PPI to 1.67 (95 % CI 1.02 to 2.75) and for steroids to 1.69 (95 % CI to 1.03 to 2.87). Hypothyroidism also substantially reduced the observed risk associated with steroid use. However, neither anemia nor hypothyroidism reduced the odds ratio for combined use of steroids and PPI. Conclusion: Our data suggest that patients who have been treated with steroids or PPIs are at an increased risk for developing CE. This study also suggests that steroids and PPI act synergistically to greatly increase the likelihood of developing CE.