Corticosteroid Use for IBD Associated With Increased Risk of Invasive Fungal Infections

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The most common invasive fungal infection was histoplasmosis and the risk of invasive fungal infections was more than double in patients treated with corticosteroids than it was for patients treated with anti-TNFs.

Certain medications for inflammatory bowel disease (IBD) are linked to higher rates of invasive fungal infections than other treatments.1

A team, led by Martin H. Gregory, MD, MSCI, Inflammatory Bowel Diseases Center, Division of Gastroenterology, Washington University School of Medicine, determined the incidence of fungal infections in patients with IBD and examined the specific risk of treatment with anti-TNF medications compared to corticosteroids.

Fungal Infections and IBD

Fungal infections can be a complication for many common treatments for IBD.

In the retrospective cohort study, the investigators identified patients in the US with IBD and at least 6 months enrollment from 2006-2018.

The investigators sought primary outcomes of the composite of invasive fungal infections, identified by ICD-9/10-CM codes plus antifungal treatment. They also sought a secondary outcome to tuberculosis (TB) infections.

Infections were presented as cases per 100,000 person-years and the team used a proportional hazards model to determine the association of IBD medications and invasive fungal infections, controlled for comorbidities and IBD severity.

The Infections

Overall, there were 652,920 patients with IBD identified and included in the final analysis. Of this group, the rate of invasive fungal infections was 47.9 cases per 100,000 person-years (95% confidence interval [CI], 44.7-51.4). This was more than double the rate of tuberculosis (n = 22 cases per 100,000 person-years; 95% CI, 20-24).

The most common invasive fungal infection was histoplasmosis (12 cases per 100,000 person-years; 95% CI, 10.4-13.8).

The investigators also controlled for comorbidities and IBD severity and found corticosteroids (hazard ratio [HR], 5.4; 95% CI, 4.6-6.2) and anti-TNFs (HR, 1.6; 95% CI, 1.3-2.1) were linked to invasive fungal infections.

“Invasive fungal infections are more common than TB in patients with IBD,” the authors wrote. “The risk of invasive fungal infections with corticosteroids is more than double that of anti-TNFs. Minimizing corticosteroid use in IBD patients may decrease the risk of fungal infections.”

Bacterial Infections and IBD

The connection between IBD treatments and bacterial infections has been looked at in recent years. For example, a 2021 study found that proton pump inhibitor (PPI) use does not lead to bacterial overgrowth in the small intestine.

Investigators from Cedars-Sinai Medical Center conducted microbiome sequencing and culture from 177 patients as part of the REIMAGINE study in order to compare duodenal and stool microbiomes in those who use and do not use PPI.

Of the total number of patients enrolled in the study, 59 subjects were on PPI at the time of endoscopy and 118 controls were not. The types of PPI being taken by subjects in the cohort using them included omeprazole (27 patients), pantoprazole (23 patients), esomeprazole (6 patients), and others (2 patients).

There were no phylum-level differences between patients that used PPI and those that did not. However, the PPI users showed significantly higher relative abundances of the families Campylobacteraceae (3.13-fold) and Bifidobacteriaceae (2.9-fold).


Martin H Gregory, MD, MSCI, Andrej Spec, MD, MSCI, Dustin Stwalley, MA, Anas Gremida, MD, Carlos Mejia-Chew, MD, Katelin B Nickel, MPH, Matthew A Ciorba, MD, Richard P Rood, MD, Margaret A Olsen, PhD, MPH, Parakkal Deepak, MBBS, MS, Corticosteroids Increase the Risk of Invasive Fungal Infections More than Tumor Necrosis Factor Alpha Inhibitors in Patients with Inflammatory Bowel Disease, Crohn's & Colitis 360, 2023;, otad010,