Oral candidiasis is a significant predictor of subsequent severe infections during immunosuppressive therapy in anti-neutrophil cytoplasmic antibody-associated vasculitis

Abstract

Background: Several studies have identified predictors of severe infections in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). However, the development of oral candidiasis (OC) as a predictor of subsequent severe infections has not been evaluated. The aim of this study was to assess the association between OC and subsequent severe infection requiring hospitalization during immunosuppressive therapy in AAV. Methods: This single-center retrospective cohort study included 71 consecutive patients with newly diagnosed AAV from Aichi Medical University Hospital, Japan, starting immunosuppressive therapy between March 2013 and December 2018. The relationships between OC and subsequent severe infections were assessed using multivariate Cox proportional hazards models, adjusted for clinically relevant factors. Results: During the follow-up period (median, 23 months; interquartile range, 11-51 months), 25 severe infectious episodes occurred in 19 patients (26.8%) and OC occurred in 17 patients (23.9%). A log-rank test showed that the OC group was significantly associated with severe infection (P < 0.001). Multivariate Cox proportional hazards models identified lower serum albumin (per 1 g/dl adjusted hazard ratio (HR)⊠= 0.38, 95% confidence interval (CI): 0.15-0.85; P⊠= âŠ0.018), use of methylprednisolone pulse (adjusted HR⊠= âŠ5.44, 95% CI: 1.54-20.0; P⊠= âŠ0.010), and OC (adjusted HR⊠= 5.31, 95% CI: 1.86-15.8; P⊠= âŠ0.002) as significant predictors of severe infection. Furthermore, a significant effect modification of the use of methylprednisolone pulse on OC was observed (P < 0.001). Conclusions: OC is one of the predictors of subsequent severe infections. The results suggest the importance of prolonging infection surveillance, especially for patients who developed OC under strong immunosuppressive therapy.