Candida biofilm production is associated with higher mortality in patients with candidaemia

Candida parapsilosis: A systematic review to inform the World Health Organization fungal priority pathogens list

Candida parapsilosis is globally distributed and recognised for causing an increasing proportion of invasive Candida infections. It is associated with high crude mortality in all age groups. It has been particularly associated with nosocomial outbreaks, particularly in association with the use of invasive medical devices such as central venous catheters. Candida parapsilosis is one of the pathogens considered in the WHO priority pathogens list, and this review was conducted to inform the ranking of the pathogen in the list. In this systematic review, we searched PubMed and Web of Science to find studies between 2011 and 2021 reporting on the following criteria for C. parapsilosis infections: mortality, morbidity (hospitalisation and disability), drug resistance, preventability, yearly incidence, and distribution/emergence. We identified 336 potentially relevant papers, of which 51 were included in the analyses. The included studies confirmed high mortality rates, ranging from 17.5% to 46.8%. Data on disability and sequelae were sparse. Many reports highlighted concerns with azole resistance, with resistance rates of >10% described in some regions. Annual incidence rates were relatively poorly described, although there was clear evidence that the proportion of candidaemia cases caused by C. parapsilosis increased over time. While this review summarises current data on C.parapsilosis, there remains an urgent need for ongoing research and surveillance to fully understand and manage this increasingly important pathogen.

Antifungal activity of nisin against clinical isolates of azole-resistant Candida tropicalis

The rapid emergence of invasive infections caused by azole-resistant Candida tropicalis has become a public health concern, and there is an urgent need for alternative treatment strategies. Studies have demonstrated the antibacterial effects of nisin, a well-known peptide naturally produced by Lactococcus lactis subsp. lactis. However, there is scant information about the antifungal effect of nisin against C. tropicalis. The present study aims to investigate the in vitro antifungal activity of nisin against clinical isolates of azole-resistant C. tropicalis strains, as well as its inhibitory effect on biofilm formation. A total of 35 C. tropicalis strains isolated from patients with invasive fungal infections were divided into the azole-resistant group and the azole-sensitive group, containing 21 and 14 strains, respectively. The relative expression levels of the ERG11 and UPC2 genes in the azole-resistant group were higher than those in the azole-sensitive group (p < 0.0001), while no significant differences were observed in the expression levels of the MDR1 and CDR1 genes. The minimum inhibitory concentration of nisin against C. tropicalis ranged from 2 to 8 μg/mL. Nisin treatment inhibited the growth of azole-resistant C. tropicalis, with over a four-fold reduction in OD600 nm values observed at the 8-h time point, while it promoted the transition of C. tropicalis from the spore phase to the hyphal phase, as observed on cryo-scanning electron microscopy. The results of biofilm quantification using crystal violet staining indicated a significant decrease in OD570 nm values in the nisin-treated group compared to the controls (p < 0.0001). Among the 21 azole-resistant C. tropicalis strains, the biofilm formation was inhibited in 17 strains (17/21, 81%), and more than 85% inhibition of biofilm formation was observed in the representative strains. With regard to the molecular mechanisms, the expression of the BCR1 and UPC2 genes in the azole-resistant strains was down-regulated on nisin treatment (p < 0.05). In conclusion, we demonstrated, for the first time, that nisin has antifungal activity and significant anti-biofilm activity against clinical isolates of azole-resistant C. tropicalis strains. Based on the findings, nisin could be a promising alternative antifungal agent for combating azole-resistant C. tropicalis infections.

Epidemiology, clinical characteristics, outcome and biofilm forming properties in candidaemia: A single-centre retrospective 4-year analysis from Hungary

BACKGROUND

Candidaemia is a life-threatening disease that is associated with high mortality, especially in intensive care units (ICUs). The number of comprehensive studies dealing with the epidemiologic characteristics of biofilm-related properties is limited.

OBJECTIVE

This study evaluated the clinical characteristics of candidaemia, to assess the biofilm-forming properties of isolates, and to identify the risk factors of mortality.

PATIENTS AND METHODS

A total of 149 candidaemia episodes from the University of Debrecen, Clinical Centre, between January 2020 and December 2023 were investigated retrospectively. The susceptibility of Candida isolates to fluconazole, amphotericin B, anidulafungin, caspofungin, and micafungin was evaluated and compared to the susceptibility of 1-day-old biofilms. Multivariate logistic regression analysis was applied to identify the independent predictors of 30-day mortality rate.

RESULTS

The most common Candida species was Candida albicans (41%), followed by C. parapsilosis (20%), C. glabrata (14%), C. tropicalis (13%), rare Candida species (7%), and C. krusei (5%). Sixty-six percent of Candida isolates were biofilm formers and 44% had high metabolic activity. The 30-day mortality rate was 52%, which was higher in ICUs (65%). The logistic regression analysis revealed several factors significantly influencing mortality including ICU admission (odds ratio [OR] 2.99, 95% confidence interval [CI] 1.17-8.04, p = 0.025), fluconazole treatment (OR 4.12, 95% CI 1.62-11.42, p = .004), and pneumonia (OR 0.261, 95% CI 0.1-0.67, p = .006).

CONCLUSIONS

This comprehensive analysis supports the better characterisation of candidaemia in healthcare settings, which ultimately may reduce mortality among patients.

Streptomyces: a natural source of anti-Candida agents

Introduction. There is an urgent need to source new compounds that can combat the current threat of serious infection caused by Candida spp. and contend with the problem of antimicrobial resistance.

Gap. A synthesis of the evidence available from the current literature is needed to identify promising antifungal chemotherapeutics.

Aim. To highlight anti-Candida compounds derived from Streptomyces spp. (a well-known source of antimicrobial compounds) that could translate to potential candidates for future clinical practice.

Methodology. A comprehensive review was conducted across three scientific literature databases spanning a 13-year period.

Results. We identified 151 compounds with anti-Candida activity. Amongst these, 40 were reported with very strong inhibitory activity, having minimum inhibitory concentrations (MICs) against Candida spp. of <3.5 µg ml−1, 66 compounds were considered strong inhibitors and 45 compounds exhibited moderate inhibitory potential. From an analysis of the MICs, we deduced that the actinomycin-like compounds RSP01 and RSP02 were probably the most promising anti-Candida compounds. Other antifungals of note included filipin-like compounds, which demonstrated superior inhibition to amphotericin B and activity against Candida glabrata and Candida krusei, and bafilomycin derivatives, which had substantial inhibition against Candida parapsilosis.

Conclusion. It is essential to recognize the limitations inherent in the quest for new antifungals, which encompass toxicity, in vivo effectiveness and constraints associated with limited data access. However, further investigation through in-depth study and emerging technologies is of paramount importance, given that there are still many more compounds to discover. This review highlights the importance of antifungal compounds derived from Streptomyces , which demonstrate robust inhibition, and, in many cases, low toxicity, making them promising candidates for the development of novel antifungal agents.

Biofilm Formation in Medically Important Candida Species

Worldwide, the number of infections caused by biofilm-forming fungal pathogens is very high. In human medicine, there is an increasing proportion of immunocompromised patients with prolonged hospitalization, and patients with long-term inserted drains, cannulas, catheters, tubes, or other artificial devices, that exhibit a predisposition for colonization by biofilm-forming yeasts. A high percentage of mortality is due to candidemia caused by medically important Candida species. Species of major clinical significance include C. albicans, C. glabrata, C. tropicalis, C. parapsilosis, C. krusei, and C. auris. The association of these pathogenic species in the biofilm structure is a serious therapeutic problem. Candida cells growing in the form of a biofilm are able to resist persistent therapy thanks to a combination of their protective mechanisms and their ability to disseminate to other parts of the body, thus representing a threat from the perspective of a permanent source of infection. The elucidation of the key mechanisms of biofilm formation is essential to progress in the understanding and treatment of invasive Candida infections.

Relationships between Secreted Aspartyl Proteinase 2 and General Control Nonderepressible 4 gene in the Candida albicans resistant to itraconazole under planktonic and biofilm conditions

This study aimed to explore the roles of SAP2 and GCN4 in itraconazole (ITR) resistance of C. albicans under different conditions, and their correlations. A total of 20 clinical strains of C. albicans, including 10 ITR resistant strains and 10 sensitive strains, were used. Then, SAP2 sequencing and GCN4 sequencing were performed, and the biofilm formation ability of different C. albicans strains was determined. Finally, real-time quantitative PCR was used to measure the expression of SAP2 and GCN4 in C. albicans under planktonic and biofilm conditions, as well as their correlation was also analyzed. No missense mutations and three synonymous mutation sites, including T276A, G543A, and A675C, were found in SAP2 sequencing. GCN4 sequencing showed one missense mutation site (A106T (T36S)) and six synonymous mutation sites (A147C, C426T, T513C, T576A, G624A and C732T). The biofilm formation ability of drug-resistant C. albicans strains was significantly higher than that of sensitive strains (P < 0.05). Additionally, SAP2 and GCN4 were up-regulated in the ITR-resistant strains, and were both significantly higher in C. albicans under biofilm condition. The mRNA expression levels of SAP2 and GCN4 had significantly positive correlation. The higher expression levels of SAP2 and GCN4 were observed in the ITR-resistant strains of C. albicans under planktonic and biofilm conditions, as well as there was a positive correlation between SAP2 and GCN4 mRNA expression.

A cell wall-targeted organic-inorganic hybrid nano-catcher for ultrafast capture and SERS detection of invasive fungi

Due to the extended culture period and various inconveniences in vitro culture, the detection of invasive fungi is rather difficult, leading to high mortality rates of the diseases caused by them. It is, however, crucial for clinical therapy and lowering patient mortality to quickly identify invasive fungus from clinical specimens. A promising non-destructive method for finding fungi is surface-enhanced Raman scattering (SERS), however, its substrate has a low level of selectivity. Clinical sample components can obstruct the target fungi's SERS signal on account of their complexity. Herein, an MNP@PNIPAMAA hybrid organic-inorganic nano-catcher was created by using ultrasonic-initiated polymerization. The caspofungin (CAS), a fungus cell wall-targeting drug, is used in this study. We investigated MNP@PNIPAMAA-CAS as a technique to rapidly extract fungus from complex samples under 3 s. SERS could subsequently be used to instantly identify the fungi that were successfully isolated with an efficacy rate of about 75%. The entire process took just 10 min. This method is an important breakthrough that might be advantageous in terms of the rapid detection of invasive fungi.

Molecular epidemiology, virulence factors, and antifungal susceptibility of Candida inconspicua strains isolated from clinical samples in Turkey

In this study, it was aimed to evaluate the molecular epidemiology, virulence factors, and antifungal susceptibility of clinical Candida inconspicua isolates. All isolates were identified by phenotypic methods and sequence analysis of ITS 1-2, D1/D2, EF-1 alpha. Proteinase, phospholipase, and esterase activities, biofilm formation, and antifungal susceptibilities were determined. All thirty isolates identified as Candida norvegensis by phenotypic methods were reidentified as C. inconspicua by sequence analysis, demonstrating the inadequacy of phenotypic methods to differentiate these 2 species. The gene regions examined in terms of determining evolutionary relatedness did not show intraspecies nucleotide variations. Therefore, different molecular approaches are needed to evaluate molecular epidemiology. Esterase, phospholipase, and biofilm formation were found to be positive in 100%, 100%, and 36.6% of the strains, respectively. The MIC₅₀/MIC₉₀ values for fluconazole and flucytosine were found to be higher than the other tested antifungals, which should be taken into account in the treatment.

Synergistic effect of bovine cateslytin-loaded nanoparticles combined with ultrasound against Candida albicans biofilm

Purpose: To investigate the synergistic effect of bovine cateslytin-loaded nanoparticles (bCAT-NPs) combined with ultrasound against Candida albicans biofilm and uncover the underlying mechanism. Methods: bCAT-NPs were prepared by the double emulsion method, and toxicity was observed by the hemolysis ratio. The metabolic activity and viable cell biomass, morphology and membrane permeability of C. albicans biofilm were observed. The expression of ALS3 mRNA, the content of reactive oxygen species, was detected. Finally, bCAT structure was analyzed. Results & conclusion: The hemolysis ratio of the bCAT-NPs group was significantly lower than that of the bCAT group. bCAT-NPs combined with ultrasound significantly reduced biofilm metabolic activity, inhibited the formation of hyphae, decreased the expression of ALS3 mRNA and increased the intracellular reactive oxygen species content. In the in vivo experiments, the colony-forming units/ml in the ultrasound+bCAT-NPs group decreased, and a few planktonic fungal cells were observed.

Advances in experimental and computational methodologies for the study of microbial-surface interactions at different omics levels

The study of the biological response of microbial cells interacting with natural and synthetic interfaces has acquired a new dimension with the development and constant progress of advanced omics technologies. New methods allow the isolation and analysis of nucleic acids, proteins and metabolites from complex samples, of interest in diverse research areas, such as materials sciences, biomedical sciences, forensic sciences, biotechnology and archeology, among others. The study of the bacterial recognition and response to surface contact or the diagnosis and evolution of ancient pathogens contained in archeological tissues require, in many cases, the availability of specialized methods and tools. The current review describes advances in in vitro and in silico approaches to tackle existing challenges (e.g., low-quality sample, low amount, presence of inhibitors, chelators, etc.) in the isolation of high-quality samples and in the analysis of microbial cells at genomic, transcriptomic, proteomic and metabolomic levels, when present in complex interfaces. From the experimental point of view, tailored manual and automatized methodologies, commercial and in-house developed protocols, are described. The computational level focuses on the discussion of novel tools and approaches designed to solve associated issues, such as sample contamination, low quality reads, low coverage, etc. Finally, approaches to obtain a systems level understanding of these complex interactions by integrating multi omics datasets are presented.

The In Vitro Activity of Fluconazole, Amphotericin B and Echinocandins Against Cyberlindnera fabianii Planktonic Cells and Biofilms

Until recently, little was known about the susceptibility pattern of Cyberlindnera fabianii (Cy. fabianii) planktonic cells and biofilms regarding the most frequently administered systemic antifungals, despite the high mortality rate and its potential role in catheter-related infections. In the current study, the activity of fluconazole, amphotericin B and echinocandins (anidulafungin, caspofungin and micafungin) was determined against planktonic and sessile cells of Cy. fabianii clinical isolates (n = 8). Planktonic minimum inhibitory concentrations (MICs) ranged from 1 to 2, from 0.25 to 1, from 0.015 to 0.06, from 0.03 to 0.12 and from 0.25 to 0.5 mg/l for fluconazole, amphotericin B, anidulafungin, caspofungin and micafungin, respectively. One-day-old biofilms were highly resistant to fluconazole (MIC ranged from 512 to > 512) compared to planktonic counterparts, but not to amphotericin B (MIC ranged from 0.25 to 2 mg/l) and echinocandins (MIC ranged from 0.06 to 2 mg/l). Based on the calculated planktonic killing rates, the highest activity was observed in the case of anidulafungin (k values ranged from 0.37 to 2.09), while micafungin, caspofungin, amphotericin B and fluconazole exerted 0.46–1.47, 0.14–0.86, −0.03 to 2.08 and −0.15 to 0.09 killing rate value ranges, respectively. The obtained in vitro planktonic and sessile susceptibility patterns suggest that echinocandins and amphotericin B may be the most reliable treatment option for the treatment of Cy. fabianii infections.

Hesperetin-Between the Ability to Diminish Mono- and Polymicrobial Biofilms and Toxicity

Hesperetin is the aglycone of citrus flavonoid hesperidin. Due to the limited information regarding hesperetin antimicrobial potential and emerging need for novel antimicrobials, we have studied its antimicrobial activity (microdilution assay), antibiofilm activity with different assays in two models (mono- and polymicrobial biofilm), and toxicity (MTT and brine shrimp lethality assays). Hesperetin inhibited growth of all Candida isolates (minimal inhibitory concentration, MIC, 0.165 mg/mL), while it’s inhibitory potential towards Staphylococcus aureus was lower (MIC 4 mg/mL). Hesperetin (0.165 mg/mL) reduced ability of Candida to form biofilms and moderately reduced exopolysaccharide levels in biofilm matrix. Effect on the eradication of 24 h old C. albicans biofilms was promising at 1.320 mg/mL. Inhibition of staphylococcal biofilm formation required higher concentrations of hesperetin (<50% inhibition with MIC 4 mg/mL). Establishment of polymicrobial C. albicans-S. aureus biofilm was significantly inhibited with the lowest examined hesperetin concentration (1 mg/mL) in crystal violet and CFU assays. Hesperetin toxicity was examined towards MRC-5 fibroblasts (IC50 0.340 mg/mL) and in brine shrimp lethality assay (LC50 > 1 mg/mL). Hesperetin is efficient in combating growth and biofilm formation of Candida species. However, its antibacterial application should be further examined due to the cytotoxic effects provoked in the antibacterial concentrations.

Assessment of Biofilm Formation by Candida albicans Strains Isolated from Hemocultures and Their Role in Pathogenesis in the Zebrafish Model

Candida albicans, an opportunistic pathogen, has the ability to form biofilms in the host or within medical devices in the body. Biofilms have been associated with disseminated/invasive disease with increased severity of infection by disrupting the host immune response and prolonging antifungal treatment. In this study, the in vivo virulence of three strains with different biofilm formation strengths, that is, non-, weak-, and strong biofilm formers, was evaluated using the zebrafish model. The survival assay and fungal tissue burden were measured. Biofilm-related gene expressions were also investigated. The survival of zebrafish, inoculated with strong biofilms forming C. albicans,, was significantly shorter than strains without biofilms forming C. albicans. However, there were no statistical differences in the burden of viable colonogenic cell number between the groups of the three strains tested. We observed that the stronger the biofilm formation, the higher up-regulation of biofilm-associated genes. The biofilm-forming strain (140 and 57), injected into zebrafish larvae, possessed a higher level of expression of genes associated with adhesion, attachment, filamentation, and cell proliferation, including eap1, als3, hwp1, bcr1, and mkc1 at 8 h. The results suggested that, despite the difference in genetic background, biofilm formation is an important virulence factor for the pathogenesis of C. albicans. However, the association between biofilm formation strength and in vivo virulence is controversial and needs to be further studied.

Evaluation of the biofilm life cycle between Candida albicans and Candida tropicalis

Candida tropicalis is an emergent pathogen with a high rate of mortality associated with its biofilm formation. Biofilm formation has important repercussions on the public health system. However, little is still known about its biofilm life cycle. The present study analyzed the biofilm life cycle of Candida albicans and C. tropicalis during various timepoints (24, 48, 72, and 96 h) through biomass assays, colony-forming unit (CFU) counting, and epifluorescence and scanning electron microscopies. Our results showed a significant difference between C. albicans and C. tropicalis biofilms in each biomass and viability assay. All-time samples in the biomass and viability assays confirmed statistical differences between the Candida species through pairwise Wilcoxon tests (p < 0.05). C. albicans demonstrated a lower biomass growth but reached nearly the same level of C. tropicalis biomass at 96 h, while the CFU counting assays exhibited a superior number of viable cells within the C. tropicalis biofilm. Statistical differences were also found between C. albicans and C. tropicalis biofilms from 48- and 72-h microscopies, demonstrating C. tropicalis with a higher number of total cells within biofilms and C. albicans cells with a superior cell area and higher matrix production. Therefore, the present study proved the higher biofilm production of C. tropicalis.

Antibiofilm Activity of Essential Fatty Acids Against Candida albicans from Vulvovaginal Candidiasis and Bloodstream Infections

Purpose

Methods

Results

Conclusion

Clinical and microbiological analysis of fungal keratitis in Toronto, Canada: A 20-year study

Fungal keratitis is a devastating and difficult-to-treat ocular infection with high morbidity. Understanding geographic microbiological and clinical trends helps to guide rapid and effective treatment. We therefore report the characteristics and outcomes of fungal keratitis in Toronto, Canada over a twenty-year period. An electronic search of microbiology records at University Health Network, Toronto, ON, Canada identified all patients with positive corneal fungal culture over a 20-year period seen at our tertiary referral cornea practice. Review of corresponding patient charts identified demographic and microbiological details, clinical course, treatment regimen, and final outcomes associated with each episode of culture-positive fungal keratitis. Forty-six patients with fifty-one discrete fungal keratitis episodes were included. Five patients experienced recurrent fungal keratitis. Candida species accounted for 60.8% of positive fungal cultures, followed by Filamentous species at 35.3%. Preferred initial anti-fungal treatment was topical amphotericin at 36.7% followed by topical voriconazole at 32.6%. Surgical intervention was required in 48.9% with therapeutic penetrating keratoplasty being the most common procedure (22.4%). Final visual acuity (VA) of < 20/200 was attributed to 58% of patients in this study. Risk factors for poor outcomes included poor VA, topical steroid use at presentation, Candida involvement, history of ocular surface disease, organic ocular trauma, or prior corneal transplantation. Candida is the most frequent keratomycotic pathogen in Toronto. Risk factors for poor visual outcome include prior corneal transplantation, ocular surface disease/trauma, or pre-existing topical steroid use. Early suspicion, diagnosis and treatment are paramount for best clinical outcomes.

Antifungal Activity of the Frog Skin Peptide Temporin G and Its Effect on Candida albicans Virulence Factors

The increasing resistance to conventional antifungal drugs is a widespread concern, and a search for new compounds, active against different species of fungi, is demanded. Antimicrobial peptides (AMPs) hold promises in this context. Here we investigated the activity of the frog skin AMP Temporin G (TG) against a panel of fungal strains, by following the Clinical and Laboratory Standards Institute protocols. TG resulted to be active against (i) Candida species and Cryptococcus neoformans, with MIC₅₀ between 4 µM and 64 µM after 24 h of incubation; (ii) dermatophytes with MIC₈₀ ranging from 4 to 32 µM, and (iii) Aspergillus strains with MIC₈₀ of 128 µM. In addition, our tests revealed that TG reduced the metabolic activity of Candida albicans cells, with moderate membrane perturbation, as proven by XTT and Sytox Green assays, respectively. Furthermore, TG was found to be effective against some C. albicans virulence factors; indeed, at 64 µM it was able to inhibit ~90% of yeast-mycelial switching, strongly prevented biofilm formation, and led to a 50% reduction of metabolic activity in mature biofilm cells, and ~30-35% eradication of mature biofilm biomass. Even though further studies are needed to deepen our knowledge of the mechanisms of TG antifungal activity, our results suggest this AMP as an attractive lead compound for treatment of fungal diseases.

Evaluation of the Antimicrobial and Antivirulent Potential of Essential Oils Isolated from Juniperus oxycedrus L. ssp. macrocarpa Aerial Parts

As a consequence of the worsening situation with multidrug-resistant (MDR) pathogens and a disparity in the commercialization of novel antimicrobial agents, scientists have been prompted to seek out new compounds with antimicrobial activity from a wide range of sources, including medicinal plants. In the present study, the antibacterial, antifungal, anti-virulence, and resistance-modulating properties of the essential oil from the Sardinian endemic Juniperus oxycedrus L. ssp. macrocarpa aerial parts were evaluated. The GC/MS analysis showed that the main compounds in the oil were α-pinene (56.63 ± 0.24%), limonene (14.66 ± 0.11%), and β-pinene (13.42 ± 0.09%). The essential oil showed potent antibacterial activity against Gram-positive bacteria (0.25–2 v/v%) and Salmonella spp. (4 v/v%). The strongest fungicidal activity was recorded against Candida auris sessile cells (median FICI was 0.088) but not against C. albicans biofilms (median FICI was 1). The oil showed potent efflux pump inhibitory properties in the case of Staphylococcus aureus and Escherichia coli. The therapeutic potential of Juniperus may be promising for future more extensive research and in vivo tests to develop new drugs against antibiotic and antifungal resistance.

Prevalence of biofilms in Candida spp. bloodstream infections: A meta-analysis

CONTEXT

Candida-related infections are nowadays a serious Public Health Problem emerging multidrug-resistant strains. Candida biofilm also leads bloodstream infections to invasive systemic infections.

OBJECTIVE

The present meta-analysis aimed to analyze Candida biofilm rate, type, and antifungal resistance among hospitalized patients between 1995 and 2020.

DATA SOURCES

Web of Science, Scopus, PubMed, and Google Scholar databases were searched for English papers using the following medical subject heading terms (MESH): "invasive candidiasis"; "bloodstream infections"; "biofilm formation"; "biofilm-related infections"; "mortality"; and "prevalence".

STUDY SELECTION

The major inclusion criteria included reporting the rate of biofilm formation and the prevalence of biofilm-related to Candida species, including observational studies (more exactly, cohort, retrospective, and case-control studies). Furthermore, data regarding the mortality rate, the geographical location of the study set, and the use of anti-fungal agents in clinical isolates were also extracted from the studies.

DATA EXTRACTION

Independent extraction of articles by 2 authors using predefined data fields, including study quality indicators.

DATA SYNTHESIS

A total of 31 studies from publicly available databases met our inclusion criteria. The biofilm formation in the data set varied greatly from 16 to 100% in blood samples. Most of the studies belonged to Europe (17/31) and Asia (9/31). Forest plot showed a pooled rate of biofilm formation of 80.0% (CI: 67-90), with high heterogeneity (Q = 2567.45, I2 = 98.83, τ2 = 0.150) in random effects model (p < 0.001). The funnel plot and Egger's linear regression test failed to find publication bias (p = 0.896). The mortality rate in Candida-related bloodstream infections was 37.9% of which 70.0% were from biofilm-associated infections. Furthermore, Candida isolates were also characterized in low, intermediate, or high biofilm formers through their level of biofilm mass (crystal violet staining or XTT assays) after a 24h growth. When comparing between countries, statistical differences were obtained (p = 0.0074), showing the lower and higher biofilm prevalence values in Italy and Spain, respectively. The prevalence of low, intermediate, and high biofilms were 36.2, 18.9, and 35.0% (p < 0.0001), respectively. C. tropicalis was the prevalent species in high biofilm formation (67.5%) showing statistically significant differences when compared to other Candida species, except for C. krusei and C. glabrata. Finally, the rates of antifungal resistance to fluconazole, voriconazole, and caspofungin related to biofilm were 70.5, 67.9 and 72.8% (p < 0.001), respectively.

CONCLUSIONS

Early detection of biofilms and a better characterization of Candida spp. bloodstream infections should be considered, which eventually will help preserve public health resources and ultimately diminish mortality among patients.

Origanum vulgare L. essential oil inhibits virulence patterns of Candida spp. and potentiates the effects of fluconazole and nystatin in vitro

Background

Recurrence and resistance of Candida spp. infections is associated with the ability of these microorganisms to present several virulence patterns such as morphogenesis, adhesion, and biofilm formation. In the search for agents with antivirulence activity, essential oils could represent a strategy to act against biofilms and to potentiate antifungal drugs.

Objective

To evaluate the antivirulence effect of Origanum vulgare L. essential oil (O-EO) against Candida spp. and to potentiate the effect of fluconazole and nystatin.

Methods

The effect of O-EO was evaluated on ATCC reference strains of C. albicans and non-albicans Candida species. Minimum inhibitory concentration (MIC) was determined through broth microdilution assay. Adhesion to microplates was determined by crystal violet (CV) assay. An adapted scratch assay in 24-well was used to determine the effect of essential oil on biofilms proliferation. Viability of biofilms was evaluated by MTT reduction assay and through a checkerboard assay we determined if O-EO could act synergistically with fluconazole and nystatin.

Results

MIC for C. albicans ATCC-90029 and ATCC-10231 was 0.01 mg/L and 0.97 mg/L, respectively. For non-albicans Candida strains MIC values were 2.6 mg/L for C. dubliniensis ATCC-CD36 and 5.3 mg/L for C. krusei ATCC-6258. By using these concentrations, O-EO inhibited morphogenesis, adhesion, and proliferation at least by 50% for the strains assayed. In formed biofilms O-EO decreased viability in ATCC 90029 and ATCC 10231 strains (IC50 7.4 and 2.8 mg/L respectively). Finally, we show that O-EO interacted synergistically with fluconazole and nystatin.

Conclusions

This study demonstrate that O-EO could be considered to improve the antifungal treatment against Candida spp.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03518-z.

Biofilm-formation capability depends on environmental oxygen concentrations in Candida species

BACKGROUND

Although oxygen concentrations inside of the human body vary depending on organs or tissues, few reports describe the relationships between biofilm formation of Candida species and oxygen concentrations. In this study, we investigated the biofilm-forming capabilities of Candida species under various oxygen conditions.

METHODS

We evaluated the adhesion and biofilm formation of Candida albicans and C. tropicalis under aerobic, microaerobic (oxygen concentration 5%), or anaerobic conditions. We also examined how oxygen concentration affects adhesion/maturation by changing adhesion/maturation phase conditions. We used crystal violet assay to estimate the approximate biofilm size, performed microscopic observation of biofilm morphology, and evaluated adhesion-associated gene expression.

RESULTS

The adhered amount was relatively small except for a clinical strain of C. tropicalis. Our biofilm-formation analysis showed that C. albicans formed a higher-size biofilm under aerobic conditions, while C. tropicalis favored microaerobic conditions to form mature biofilms. Our microscopic observations were consistent with these biofilm-formation analysis results. In particular, C. tropicalis exhibited more hyphal formation under microaerobic conditions. By changing the adhesion/maturation phase conditions, we represented that C. albicans had favorable biofilm-formation capability under aerobic conditions, while C. tropicalis showed enhanced biofilm formation under microaerobic adhesion conditions. In good agreement with these results, the C. tropicalis adhesion-associated gene expression tended to be higher under microaerobic or anaerobic conditions.

CONCLUSIONS

C. albicans favored aerobic conditions to form biofilms, whereas C. tropicalis showed higher biofilm-formation ability and promoted hyphal growth under microaerobic conditions. These results indicate that favorable oxygen conditions significantly differ for each Candida species.

Probiotics: Potential Novel Therapeutics Against Fungal Infections

The global infection rate of fungal diseases is increasing year by year, and it has gradually become one of the most serious infectious diseases threatening human health. However, the side effects of antifungal drugs and the fungal resistance to these drugs are gradually increasing. Therefore, the development of new broad-spectrum, safe, and economical alternatives to antibacterial drugs are essential. Probiotics are microorganisms that are beneficial for human health. They boost human immunity, resist pathogen colonization, and reduce pathogen infection. Many investigations have shown their inhibitory activity on a wide range of pathogenic fungi. However, their antibacterial mechanism is still a secret. This article reviews the progress of probiotics as a new method for the treatment of fungal diseases.

Antifungal lock therapy: an eternal promise or an effective alternative therapeutic approach?

Each year, millions of central venous catheter insertions are performed in intensive care units worldwide. The usage of these indwelling devices is associated with a high risk of bacterial and fungal colonization, leading to the development of microbial consortia, namely biofilms. These sessile structures provide fungal cells with resistance to the majority of antifungals, environmental stress and host immune responses. Based on different guidelines, colonized/infected catheters should be removed and changed immediately in the case of Candida‐related central line infections. However, catheter replacement is not feasible for all patient populations. An alternative therapeutic approach may be antifungal lock therapy, which has received high interest, especially in the last decade. This review summarizes the published Candida‐related in vitro, in vivo data and case studies in terms of antifungal lock therapy. The number of clinical studies remains limited and further studies are needed for safe implementation of the antifungal lock therapy into clinical practice.

How does temperature trigger biofilm adhesion and growth in Candida albicans and two non-Candida albicans Candida species?

BACKGROUND

Biofilm formation on biotic and abiotic surfaces is finely regulated by genetic factors but also by oxygen concentration, pH, temperature and other environmental factors, already extensively explored for bacterial biofilms. Much less is known about fungal biofilm, that is considered a virulence factor for Candida pathogenic species among the few fungal species able to grow and survive at high temperatures such as 37°C as well as those induced by fever. The resistance to high temperatures coupled with the ability to form biofilm are threatening factors of these fungal species that could severely impact at an epidemiological level.

OBJECTIVES

In this framework, we decided to study the thermal tolerance of biofilms formed by three medical relevant species such as Candida albicans and two non-Candida albicans Candida species.

METHODS

Thirty nosocomial strains were investigated for their ability to adhere and grow in proximity and over body temperature (from 31 to 43°C), mimicking different environmental conditions or severe febrile-like reactions.

RESULTS

Candida sessile cells reacted to different temperatures showing a strain-specific response. It was observed that the attachment and growth respond differently to the temperature and that mechanism of adhesion has different outputs at high temperature than the growth.

CONCLUSIONS

This strain-dependent response is probably instrumental to guarantee the best success to cells for the infection, attachment and growth to occur. These observations reinforce the concept of temperature as a major trigger in the evolution of these species especially in this period of increasing environmental temperatures and excessive domestic heating.

Rapid detection of biofilm-producing Candida species via MALDI-TOF mass spectrometry

AIMS

The aim of this study was to evaluate the formation of biofilm by Candida spp. isolated from the bloodstream, using traditional spectrophotometric methodologies. In addition, the goal was to compare the results with those obtained through MALDI-TOF/MS, as well as to verify its use as a potential tool for the detection of biofilm-forming strains.

METHODS AND RESULTS

Hundred and thirteen isolates of Candida spp. were studied: 41 were Candida albicans, 27 C. tropicalis, 18 C. glabrata, 17 C. parapsilosis and 10 C. krusei. Metabolic activity was determined through the tetrazolium salt (XTT) reduction assay and biomass by staining with Crystal Violet. All isolates were able to form biofilm, 94% of which were strong producers, with high biomass quantification (95%; 107/113) and high metabolic activity (99%; 112/113). Mass spectra of the biofilm-producing isolates showed differences in the intensity of mass peaks when compared with the spectra of the nonproducing strains.

CONCLUSIONS

It was demonstrated that MALDI-TOF/MS was able to detect specific biofilm proteins, as the mass spectra of the isolates presented differences when compared with nonproducing strains.

SIGNIFICANCE AND IMPACT OF THE STUDY

MALDI-TOF/MS can become a valuable tool for biofilm detection at the moment of the identification of the microorganism, thus contributing greatly to the management of patients with Candidemia.

Adolescent eating disorder with catheter-related bloodstream infection

BACKGROUND

Treatment of adolescent eating disorder requires early improvement of nutritional status. Central venous hyperalimentation is used but catheter-related bloodstream infection (CRBSI) is a complication. There have been no reports examining risk factors for CRSBI in eating disorders.

METHODS

The subjects were 51 patients who received nutritional therapy with the use of a peripherally inserted central catheter (PICC) from January 2012 to December 2019. The courses of weight and white blood cell (WBC) count were examined retrospectively during nutritional therapy. Onset factors for CRBSI were determined and a case series of CRBSI caused by Candida parapsilosis is presented.

RESULTS

The day of minimum weight occurred on or before day 7 in 37 of the 51 patients, and this day was preceded by the day with the lowest WBC at a significant rate. The minimum weight day was significantly delayed in CRSBI cases compared with non-CRBSI cases (P = 0.02). In the case series of CRBSI caused by C. parapsilosis, the median WBC count before CRBSI decreased to 2,570 (1,680-3,270)/μL at a median of day (12-90) 36. Catheter-related bloodstream infection developed at a median of day (26-133) 38. The PICC was immediately removed and an antifungal drug was started, leading to cure with no after effects in all subjects.

CONCLUSIONS

In patients with an eating disorder treated with nutritional therapy using a PICC, prolonged resistance to weight gain became a risk factor for developing CRBSI. White blood cell counts recover after weight gain, which suggests that there is a risk of developing CRBSI, even with improved appetite and weight gain.

The relationship between biofilm formation and mortality in patients with Candida tropicalis candidemia

BACKGROUND

Biofilm formation by Candida species is an influential virulence factor in candidemia pathogenesis. We investigated the relationship between biofilm formation of Candida tropicalis isolates with the clinical characteristics and mortality outcomes in patients with candidemia.

MATERIALS AND METHODS

Thirty-nine C. tropicalis isolates were recovered from patients with candidemia admitted to two university hospitals in Tehran, Iran. Biofilm mass and metabolic activity of C. tropicalis biofilms were assessed in vitro with two colorimetric methods. The sessile minimum inhibitory concentrations (SMICs) were evaluated in vitro by treating preformed biofilms with diluted concentrations of azoles according to CLSI-M27 A3/S4 protocol, followed by metabolic activity quantification. The expressions of ERG11, UPC2, MDR1, and CDR1 genes were also evaluated.

RESULTS

All C. tropicalis isolates produced biofilm. Respectively, higher <7-day and ≥7-day mortality rates were found among cases with high metabolic activity (46.7% vs. 13%, P = 0.03) and high biofilm mass (31.8% vs. 0, P = 0.029). Sessile cells had high resistance to fluconazole, voriconazole, and itraconazole. The azole minimum inhibitory concentrations (MICs) of C. tropicalis sessile were significantly greater than the planktonic minimum inhibitory concentrations (PMICs). In fluconazole-treated biofilms, the expression of ERG11 and UPC2 genes was increased.

CONCLUSION

Our findings highlight the importance of C. tropicalis biofilm formation as an important factor in candidemia pathogenesis and the clinical outcome of patients with candidemia.

Biologically rapid synthesized silver nanoparticles from aqueous Eucalyptus camaldulensis leaf extract: Effects on hyphal growth, hydrolytic enzymes, and biofilm formation in Candida albicans

Bionanotechnology has increasingly gained attention in biomedical fields as antifungal and antibiofilm agents. In this study, biosynthesized silver nanoparticles (bio-AgNPs) using aqueous Eucalyptus camaldulensis leaf extract were successfully performed by a one-step green approach. Spherical-shaped nanoparticles, approximately 8.65 nm, exhibited noncytotoxicity to erythrocytes, HeLa, and HaCaT cells. The synthesized nanoparticles showed strong fungicidal activity ranging from 0.5 to 1 µg/ml. The nanoparticles affected Candida adhesion and invasion into host cells by reduced germ tube formation and hydrolytic enzyme secretion. Inhibitory effects of bio-AgNPs on Candida biofilms were evaluated by the prevention of yeast-to-hyphal transition. A decrease in cell viability within mature biofilm demonstrated the ability of bio-AgNPs to penetrate into the extracellular matrix and destroy yeast cell morphology, leading to cell death. Molecular biology study on biofilms confirmed downregulation in the expression of genes ALS3, HWP1, ECE1, EFG1, TEC1, ZAP1, encoding hyphal growth and biofilm development and PLB2, LIP9, SAP4, involved in hydrolytic enzymes. In addition to candida treatment, the bio-AgNPs could be applied as an antioxidant to protect against oxidative stress-related human diseases. The findings concluded that bio-AgNPs could be used as an antifungal agent for candida treatment, as well as be incorporated in medical devices to prevent biofilm formation.

Candida Pathogenicity and Interplay with the Immune System

Candida species are opportunistic fungal pathogens that are part of the normal skin and mucosal microflora. Overgrowth of Candida can cause infections such as thrush or life-threatening invasive candidiasis in immunocompromised patients. Though Candida albicans is highly prevalent, several non-albicans species are also isolated from nosocomial infections. Candida sp. are over presented in the gut of people with Crohn's disease and certain types of neurological disorders, with hyphal form and biofilms being the most virulent states. In addition, Candida uses several secreted and cell surface molecules such as pH related antigen 1, High affinity glucose transporter, Phosphoglycerate mutase 1 and lipases to establish pathogenicity. A strong innate immune response is elicited against Candida via dendritic cells, neutrophils and macrophages. All three complement pathways are also activated. Production of proinflammatory cytokines IL-10 and IL-12 signal differentiation of CD4⁺ cells into Th1 and Th2 cells, whereas IL-6, IL-17 and IL-23 induce Th17 cells. Importance of T-lymphocytes is reflected in depleted T-cell count patients being more prone to Candidiasis. Anti- Candida antibodies also play a role against candidiasis using various mechanisms such as targeting virulent enzymes and exhibiting direct candidacidal activity. However, the significance of antibody response during infection remains controversial. Furthermore, some of the Candida strains have evolved molecular strategies to evade the sophisticated host attack by proteolysis of components of immune system and interfering with immune signalling pathways. Emergence of several non-albicans species that are resistant to current antifungal agents makes treatment more difficult. Therefore, deeper insight into interactions between Candida and the host immune system is required for discovery of novel therapeutic options.

Changes in Adhesion of Candida tropicalis Clinical Isolates Exhibiting Switch Phenotypes to Polystyrene and HeLa Cells

BACKGROUND

Candida tropicalis is an important human pathogen that can undergo multiple forms of phenotypic switching.

AIM

We aimed to evaluate the effect of phenotypic switching on the adhesion ability of C. tropicalis.

METHODS

C. tropicalis morphotypes included parental phenotypes (clinical isolates) and switch phenotypes (crepe, revertant of crepe-CR, rough, revertant of rough-RR, irregular center and revertant of irregular center-ICR). Adhesion to polystyrene and HeLa cells was determined by crystal violet assay. The percentage of HeLa cells with adhered yeasts and the number of adhered yeasts per HeLa cell were determined by light microscopy. Filamentation among adhered cells was assessed by direct counting.

RESULTS

On polystyrene, 60% of the switch strains showed difference (p < 0.05) on adhesion ability compared to their parental counterpart strains, and altered thickness of adhered cells layers. Filamentation was increased among adhered cells of the switched strains compared to parental strains. A positive correlation was observed between adhesion on polystyrene and filamentation for morphotypes of the system 49.07. The majority of the switched strains showed higher adhesion capability to HeLa cells in comparison to the adherence of the clinical strains. All revertant strains showed a higher number of yeast cells per HeLa cell compared to their variant counterparts (p < 0.05), with exception of the ICR.

CONCLUSIONS

Our findings indicate that switching events in C. tropicalis affect adhesion and filamentation of adhered cells on polystyrene and HeLa cells. The rise of switch strains with increased adhesion ability may contribute to the success of infection associated with C. tropicalis.

Role of arthroconidia in biofilm formation by Trichosporon asahii

BACKGROUND

Trichosporon asahii is the major causative agent of disseminated and deep-seated trichosporonosis. It is capable of forming biofilms on surfaces, leading to medical device-related infection.Trichosporon asahii may be present as yeast form, hyphae and/or arthroconidia; however, the relationship between its biofilm-forming ability and its morphological transition is unclear.

OBJECTIVES

We investigated whether the T. asahii morphological transition contributes to its biofilm formation. We also determined the conditions required to induce each of the morphologies.

METHODS

Three high- and three low-biofilm-producing strains (HBS and LBS, respectively) were selected using a biofilm formation assay, and the cell surface hydrophobicity of these six strains was measured. For each strain, the morphology was observed and the number of each morphological form (yeast form, hypha and arthroconidium) was counted to calculate the ratio. Finally, the ability of cells each morphological type to adhere to the polystyrene substrate was evaluated.

RESULTS

The HBS exhibited abundant arthroconidia and hyphae; in contrast, the LBS produced mainly hyphae with few or no arthroconidia. The production of hyphae was increased by nitrogen-containing medium, and the production of arthroconidia was increased by nitrogen-deficient medium. Cells incubated under nitrogen-deficient conditions showed higher adherence to a polystyrene surface than those incubated in the presence of nitrogen.

CONCLUSION

Arthroconidia of T. asahii play a key role in biofilm formation by promoting cellular adhesion.

Fungal arthritis with adjacent osteomyelitis caused by Candida pelliculosa: a case report

Background

Candida sp. osteoarticular infection is rare and most often due to hematogenous seeding during an episode of candidemia in immunocompromised patients. However, the diagnosis can be delayed in patients with subtle symptoms and signs of joint infection without a concurrent episode of candidemia.

Case presentation

A 75-year-old woman presented with a three-year history of pain and swelling of the left knee. Candida pelliculosa was detected from the intraoperative tissue when the patient had undergone left total knee arthroplasty 32 months ago, but no antifungal treatment was performed. One year after the total knee arthroplasty, C. pelliculosa was repeatedly isolated from the left knee synovial fluid and antifungal treatment comprising amphotericin B deoxycholate and fluconazole was administered. However, joint infection had extended to the adjacent bone and led to progressive joint destruction. The patient underwent surgery for prosthesis removal and received prolonged antifungal treatment with micafungin and fluconazole.

Conclusions

This case shows that C. pelliculosa, an extremely rare non-Candida albicans sp., can cause fungal arthritis and lead to irreversible joint destruction owing to delayed diagnosis and treatment.

Effect of phenotypic switching on biofilm traits in Candida tropicalis

Candida tropicalis can undergo multiple forms of phenotypic switching. We have reported a switching system in C. tropicalis that is associated with changes in virulence attributes. We aimed to assess biofilm formation by distinct switch states of C. tropicalis and evaluate whether their sessile cells exhibit altered virulence traits. C. tropicalis strains included the parental phenotype (a clinical isolate) and four switch phenotypes (crepe, rough, revertant of crepe and revertant of rough). Biofilm formation and adhesion capability of sessile cells on polystyrene were assessed through quantification of total biomass. Filamentous forms were characterized by direct counting of sessile cells. A virulence assay was conducted using the Galleria mellonella infection model. Switch variants (crepe and rough) and their revertant counterparts produced higher biofilm biomass (P < 0.05) than the parental strain. Additionally, filamentous forms were enriched among sessile cells of switched strains compared to those observed for sessile cells of the parental strain, with the exception of the revertant of rough. Sessile cells of switched strains showed higher adhesion to polystyrene compared to the parental strain. Sessile cells of the crepe variant and its revertant strain (RC) exhibited higher virulence against G. mellonella larvae than sessile cells of the parental strain. Our findings indicate that switching events in C. tropicalis affect biofilm development and that sessile cells of distinct switch states may exhibit increased adhesion ability and enhanced virulence towards G. mellonella larvae.