Glucocorticoid use and candidemia: results from a nationwide case-control study

Glucocorticoids are widely used for acute and chronic diseases. Although their association with increased infection risk is well-established, population-level data on glucocorticoid use and candidemia are limited. We investigated the association between oral glucocorticoid exposure and candidemia in a population-based setting over 14 years, with attention to variation by dose, Candida species and underlying disease.

We conducted a nationwide, registry-based case-control study (2010-2024) including all Danish adults with a first-time Candida bloodstream infection (cases), matched to ten population controls. Glucocorticoid use was defined as redemption of an oral glucocorticoid prescription within 90 days before the index date, categorized by 90-day prednisolone-equivalent cumulative dose. Adjusted odds ratios (aORs) with 95% CIs were estimated using conditional logistic regression. Subgroup analyses evaluated variation by species and underlying conditions.

We included 6179 cases and 61 790 controls. Glucocorticoid use was associated with higher odds of candidemia overall (aOR: 2.17, 95% CI: 1.92-2.45), and across major species groups including C. albicans (aOR: 2.22, 95% CI: 1.86-2.65), C. glabrata (aOR: 2.08, 95% CI: 1.70-2.55), C. tropicalis (aOR: 2.22, 95% CI: 1.22-4.04), C. krusei (aOR: 2.38, 95% CI: 1.26-4.48), C. parapsilosis (aOR: 2.80, 95% CI: 1.62-4.85), but not C. dubliniensis (aOR: 1.45, 95% CI: 0.68-3.09). The odds increased with higher cumulative doses (<750 mg; aOR: 1.59, 95% CI: 1.35-1.86, 750-1500 mg; aOR: 2.25, 95% CI: 1.75-2.90, and >1500 mg; aOR: 5.23, 95% CI: 4.01-6.83, compared to nonusers). The highest odds were observed among patients with inflammatory bowel disease (aOR: 4.62, 95% CI: 2.21-9.43), followed by rheumatic disease (aOR: 3.15, 95% CI: 2.28-4.35), and chronic pulmonary disease (aOR: 2.07, 95% CI: 1.67-2.56).

Glucocorticoid use is associated with increased candidemia odds with a clear dose-dependent relationship, consistent across common Candida species, and most pronounced in inflammatory bowel disease, rheumatic disease, and chronic pulmonary disease.