Respiratory Infections
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Proton Pump Inhibitors and Risk of Infection: Is Suppression of Immune Defence Molecules to Blame?

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Published Online: Oct 18th 2021 touchREVIEWS in Respiratory & Pulmonary Diseases. 2021;6(1):3–4 DOI:
Authors: Yohannes T Ghebre
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Over the last decade, bioinformatics studies and case reports have found a significant association between proton pump inhibitor (PPI) use and the risk of microbial infection. However, the mechanism of increased infection risk remains unknown. Emerging molecular, cell biological and animal studies indicate that PPIs exhibit pleiotropic activity that suppresses inflammatory cytokines that are bona fide immune defence molecules. Accordingly, the purpose of this editorial is to discuss biologically plausible concepts for how PPIs may increase the risk of microbial infections.


Proton pump inhibitors, infection risk, immune defence molecules


Proton pump inhibitors (PPIs) are a class of antacid drugs that are available by prescription and over-the-counter to treat gastro-oesophageal reflux disease in patients with a number of comorbidities, including chronic respiratory diseases, such as asthma, pulmonary arterial hypertension, chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis.1 Although they are generally regarded as safe and effective antacid drugs, there are growing medical concerns over their prolonged use.2 One of the concerns associated with long-term PPI use is the increased risk of microbial infections.3 Several bioinformatics studies and case reports indicate that PPI use is associated with the risk of community-acquired pneumonia.4–6

Intriguingly, the increased infection risk with PPI use does not appear to be reproduced with the use of an alternate class of antacids, histamine H2-receptor antagonists (H2RAs), suggesting that it is unlikely that the change in gastric pH is responsible for the increased risk of infection in PPI users. Accordingly, no mechanistic data exist to explain why PPI use is associated with an increased risk of microbial infections. In this regard, emerging molecular, cell biological and preclinical in vivo data show that PPIs – but not H2RAs – possess biological activities targeted against several immune defence molecules, including tumour necrosis factor alpha (TNFα), interleukin (IL)-1 beta (IL-1β), IL-6 and nuclear factor kappa B (NFκB).7–9 Moreover, PPIs inhibit the activation of neutrophils and monocytes, and deplete intracellular and extracellular neutrophil reactive oxygen species (ROS) and nitric oxide (NO) to impair bactericidal activity.10 Additional studies also have reported that PPIs target inducible nitric oxide synthase (iNOS) and several members of the integrin family including CD11b (integrin αMβ2) and CD18 (integrin β2).7,10–13 Furthermore, several studies have reported significant regulation of TGFβ signalling and the Wnt/β-catenin pathway by PPIs to modulate cell fate, including epithelial-to-mesenchymal transition.7,14–16

It is known that almost all of these biological processes are involved in innate immune defence mechanisms against invading pathogens, including bacteria, viruses and fungi. For example, members of the TNFα superfamily play a significant role in homeostatic processes, including the development and function of the immune system, such as activation of innate lymphoid cells and natural killer cells to limit infections.17 In addition, TNF is able to induce the expression of chemokines and adhesion molecules to participate in the recruitment of neutrophils to the site of infection to contain initial infections.18 In macrophages, TNF has been shown to activate NFκB to enforce an antimicrobial immune defence.19 Moreover, the generation of ROS and NO, two powerful antimicrobial effectors, is reported to be controlled by TNF.20,21 The NFκB pathway is central in the first line of defence against invading pathogens, in part, by being involved in the regulation of innate and adaptive immune response to support T-cell maturation and proliferation. In addition, this pathway is involved in the generation of inflammatory cytokines and other antimicrobial molecules that are necessary in the recruitment of phagocytes and for microbial clearance.22–24

Studies have also demonstrated that interleukins, such as IL-1β and IL-6 induce non-specific resistance to microbial infections.25,26 Another PPI-targeted molecule that is essential in mounting an immune defence against microbial infection is iNOS. This inducible isoform of NO synthase, or the NO generated by iNOS, has been reported to be involved in controlling the intracellular growth of bacteria and in preventing bacterial infection-induced lethality in animal models.27,28 Finally, integrins are involved in cellular processes, including cell adhesion, migration, T-cell activation and phagocytosis to support the immune system. For example, CD11b is expressed in macrophages, monocytes and dendritic cells, which are major cell types that are involved in the innate immune response against microbial infections.29 Furthermore, PPIs may have a direct or indirect effect on the gut microbiome, including bacterial overgrowth and imbalance in the composition of gut microbiota.3,30


Emerging studies indicate that PPIs possess anti-inflammatory activity that extends from the inhibition of classic inflammatory molecules, such as TNFα, interleukins, iNOS and NFκB, to the suppression of adhesion molecules, such as ROS and nitrogen species, and the regulation of inflammatory cells, such as neutrophils and monocytes, without clear evidence about the mechanism of action. Although this multi-faceted, anti-inflammatory activity of PPIs could be harnessed for therapeutic purposes, downregulating inflammatory cells and molecules also impacts proper immune function, including a physiological response to microbial infection, which raises the question of whether the immunosuppressive potential of PPIs is the missing link between prolonged use of the drug and increased risk of infection in some patients. In this regard, additional molecular and pharmacovigilance studies are required to address the possibility of a causal relationship. In the meantime, clinicians should supervise at-risk patients, including the elderly and immunocompromised, from possible harm related to long-term PPI use.

Article Information:

Yohannes T Ghebre is an inventor on patents, owned by Stanford University and Baylor College of Medicine, that protect the use of agents, including proton pump inhibitors, for therapeutic use of new indications. Yohannes T Ghebre receives grants from the National Heart, Lung, and Blood Institute (NHLBI; grant numbers: K01HL118683; R01HL137703),National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS; grant number: R56AR077445), American Heart Association (grant number: 17GRNT33460159), the Cancer Prevention and Research Institute of Texas (grant number: RP190497) and by intramural funding from Baylor College of Medicine (project ID: 2690000104). This content is solely the responsibility of the author and does not necessarily represent the official views of the sponsors.

Compliance With Ethics

This article involves a review of the literature and did not involve any studies with human or animal subjects performed by any of the authors.

Review Process

Double-blind peer review.


The named author meets the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, takes responsibility for the integrity of the work as a whole, and has given final approval for the version to be published.


Yohannes T Ghebre, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.



No funding was received for the publication of this article.


This article is freely accessible at © Touch Medical Media 2021.




  1. Ghebre YT, Raghu G. Idiopathic pulmonary fibrosis: novel concepts of proton pump inhibitors as antifibrotic drugs.Am J Respir Crit Care Med. 2016;193:1345–52.
  2. Yu LY, Sun LN, Zhang XH, et al. A review of the novel application and potential adverse effects of proton pump inhibitors. Adv Ther.2017;34:1070–86.
  3. Singh A, Cresci GA, Kirby DF. Proton pump inhibitors: risks and rewards and emerging consequences to the gut microbiome. Nutr Clin Pract. 2018;33:614–24.
  4. Meijvis SC, Cornips MC, Voorn GP, et al. Microbial evaluation of proton-pump inhibitors and the risk of pneumonia. Eur Respir J.2011;38:1165–72.
  5. Lazaro-Pacheco IB, Servin-Caamano AI, Perez-Hernandez JL, et al. Proton pump inhibitors increase the overall risk of developing bacterial infections in patients with cirrhosis. Arq Gastroenterol. 2018;55:28–32.
  6. Zirk-Sadowski J, Masoli JA, Delgado J, et al. Proton-pump inhibitors and long-term risk of community-acquired pneumonia in older adults. J Am Geriatr Soc. 2018;66:1332–8.
  7. Ghebremariam YT, Cooke JP, Gerhart W, et al. Pleiotropic effect of the proton pump inhibitor esomeprazole leading to suppression of lung inflammation and fibrosis. J Transl Med. 2015;13:249.
  8. Ghebre YT. Proton pump inhibitors in IPF: a call for clinical trials. Front Pharmacol.2018;9:499.
  9. Pham N, Ludwig MS, Wang M, et al. Topical esomeprazole mitigates radiation-induced dermal inflammation and fibrosis. Radiat Res.2019;192:473–82.
  10. Zedtwitz-Liebenstein K, Wenisch C, Patruta S, et al. Omeprazole treatment diminishes intra- and extracellular neutrophil reactive oxygen production and bactericidal activity. Crit Care Med. 2002;30:1118–22.
  11. Montaldo C, Cannas E, Ledda M, et al. Bronchoalveolar glutathione and nitrite/nitrate in idiopathic pulmonary fibrosis and sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis. 2002;19:54–8.
  12. Yoshida N, Yoshikawa T, Tanaka Y, et al. A new mechanism for anti-inflammatory actions of proton pump inhibitors–inhibitory effects on neutrophil-endothelial cell interactions. Aliment Pharmacol Ther.2000;14 (Suppl. 1):74–81.
  13. Sasaki T, Yamaya M, Yasuda H, et al. The proton pump inhibitor lansoprazole inhibits rhinovirus infection in cultured human tracheal epithelial cells. Eur J Pharmacol.2005;509:201–10.
  14. Morse D, Choi AM. Heme oxygenase-1: from bench to bedside. Am J Respir Crit Care Med. 2005;172:660–70.
  15. Kikuchi N, Ishii Y, Morishima Y, et al. Nrf2 protects against pulmonary fibrosis by regulating the lung oxidant level and Th1/Th2 balance. Respir Res. 2010;11:31.
  16. Cho HY, Reddy SP, Yamamoto M, et al. The transcription factor NRF2 protects against pulmonary fibrosis. FASEB J. 2004;18:1258–60.
  17. Šedý J, Bekiaris V, Ware CF. Tumor necrosis factor superfamily in innate immunity and inflammation. Cold Spring Harb Perspect Biol.2014;7:a016279.
  18. Mizgerd JP, Spieker MR, Doerschuk CM. Early response cytokines and innate immunity: essential roles for TNF receptor 1 and type I IL-1 receptor during Escherichia coli pneumonia in mice.J Immunol. 2001;166:4042–8.
  19. Gutierrez MG, Mishra BB, Jordao L, et al. NF-kappa B activation controls phagolysosome fusion-mediated killing of mycobacteria by macrophages. J Immunol. 2008;181:2651–63.
  20. Liew FY, Li Y, Millott S. Tumor necrosis factor-alpha synergizes with IFN-gamma in mediating killing of Leishmania majorthrough the induction of nitric oxide. J Immunol. 1990;145:4306–10.
  21. Blaser H, Dostert C, Mak TW, et al. TNF and ROS crosstalk in inflammation. Trends Cell Biol.2016;26:249–61.
  22. Bonizzi G, Karin M. The two NF-kappaB activation pathways and their role in innate and adaptive immunity. Trends Immunol. 2004;25:280-8.
  23. Gerondakis S, Siebenlist U. Roles of the NF-kappaB pathway in lymphocyte development and function. Cold Spring Harb Perspect Biol. 2010;2:a000182.
  24. Liu T, Zhang L, Joo D, Sun S-C. NF-kB signaling in inflammation. Signal Transduct Target Ther. 2017;2:17023.
  25. Vogels MT, Eling WM, Otten A, et al. Interleukin-1 (IL-1)-induced resistance to bacterial infection: role of the type I IL-1 receptor. Antimicrob Agents Chemother.1995;39:1744–7.
  26. Kuo TM, Hu CP, Chen YL, et al. HBV replication is significantly reduced by IL-6. J Biomed Sci.2009;16:41.
  27. Sasaki S, Miura T, Nishikawa S, et al. Protective role of nitric oxide in Staphylococcus aureusinfection in mice. Infect Immun. 1998;66:1017–22.
  28. Utaisincharoen P, Anuntagool N, Arjcharoen S, et al. Induction of iNOS expression and antimicrobial activity by interferon (IFN)-beta is distinct from IFN-gamma in Burkholderia pseudomallei-infected mouse macrophages. Clin Exp Immunol. 2004;136:277–83.
  29. Pilione MR, Agosto LM, Kennett MJ, et al. CD11b is required for the resolution of inflammation induced by Bordetella bronchisepticarespiratory infection. Cell Microbiol. 2006;8:758–68.
  30. Bruno G, Zaccari P, Rocco G, et al. Proton pump inhibitors and dysbiosis: current knowledge and aspects to be clarified. World J Gastroenterol.2019;25:2706–19.

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