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Candida albicans Biofilms Produce Antifungal-Tolerant Persister Cells
Open accessAbstract
Fungal pathogens form biofilms that are highly recalcitrant to antimicrobial therapy. The expression of multidrug resistance pumps in young biofilms has been linked to increased resistance to azoles, but this mechanism does not seem to underlie the resistance of mature biofilms that is a model of in vivo infection. The mechanism of drug resistance of mature biofilms remains largely unknown. We report that biofilms formed by the major human pathogen Candida albicans exhibited a strikingly biphasic killing pattern in response to two microbicidal agents, amphotericin B, a polyene antifungal, and chlorhexidine, an antiseptic, indicating that a subpopulation of highly tolerant cells, termed persisters, existed. The extent of killing with a combination of amphotericin B and chlorhexidine was similar to that observed with individually added antimicrobials. Thus, surviving persisters form a multidrug-tolerant subpopulation. Interestingly, surviving C. albicans persisters were detected only in biofilms and not in exponentially growing or stationary-phase planktonic populations. Reinoculation of cells that survived killing of the biofilm by amphotericin B produced a new biofilm with a new subpopulation of persisters. This suggests that C. albicans persisters are not mutants but phenotypic variants of the wild type. Using a stain for dead cells, rare dark cells were visible in a biofilm after amphotericin B treatment, and a bright and a dim population were physically sorted from this biofilm. Only the dim cells produced colonies, showing that this method allows the isolation of yeast persisters. Given that persisters formed only in biofilms, mutants defective in biofilm formation were examined for tolerance of amphotericin B. All of the known mutants affected in biofilm formation were able to produce normal levels of persisters. This finding indicates that attachment rather than formation of a complex biofilm architecture initiates persister formation. Bacteria produce multidrug-tolerant persister cells in both planktonic and biofilm populations, and it appears that yeasts and bacteria have evolved analogous strategies that assign the function of survival to a small part of the population. In bacteria, persisters are dormant cells. It remains to be seen whether attachment initiates dormancy that leads to the formation of fungal persisters. This study suggests that persisters may be largely responsible for the multidrug tolerance of fungal biofilms.
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“Currently, antifungal persistence is mainly identified in Candida-associated biofilms [2,32,33].”
From Antifungal persistence: Clinical relevance and mechanisms (2025) · cites this paper as [2]
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“Antifungal persistence is most commonly observed in biofilm rather than in planktonic cells [2,33,34]”
From Antifungal persistence: Clinical relevance and mechanisms (2025) · cites this paper as [2]
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“To solve these problems, live/dead staining method can be applied because of its ability to distinguish live/dead cells, which reflects the essence of persisters that survive exposure to fungicides.”
From Antifungal persistence: Clinical relevance and mechanisms (2025) · cites this paper as [2]
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“For example, C. albicans persister biofilms are recalcitrant to AmB and broad-spectrum antimicrobial agent chlorhexidine [2];”
From Antifungal persistence: Clinical relevance and mechanisms (2025) · cites this paper as [2]
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“indicating that antifungal persistence is not solely dependent on matured biofilm structure formation [2].”
From Antifungal persistence: Clinical relevance and mechanisms (2025) · cites this paper as [2]
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“However, LaFleur and colleagues first reported that the biofilm-deficient double mutant strain efg1Δ/cph1Δ did not result in the reduction of AmB-triggered persisters”
From Antifungal persistence: Clinical relevance and mechanisms (2025) · cites this paper as [2]
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“Inside the biofilm cell population, persister cells form a unique group that is formed randomly, phenotypically dormant, highly tolerant to antifungal drugs [164], and which is a key mechanism of resistance in chronic infections [130].”
From Candida glabrata Biofilms: How Far Have We Come? (2017) · cites this paper as [164]
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“A minor subset of metabolically dormant yeast cells that stochastically arise as phenotypical variants within biofilms, persister cells are extremely resistant to antifungal drugs (100).”
From Candida albicans Biofilms and Human Disease (2015) · cites this paper as [100]
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“Although we know little about the formation and roles of persister cells in C. albicans biofilms, we do know that the drug resistance of persister cells is independent of cell membrane composition and efflux pump expression; rather, it is the result of the metabolically dormant state of the cells (88, 100).”
From Candida albicans Biofilms and Human Disease (2015) · cites this paper as [100]
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Metadata
- Authors
- LaFleur, M. D., Kumamoto, C. A., & Lewis, K.
- Affiliations
- Northeastern University (US)
- Tufts University (US)
- Corresponding author
- Lewis, Kim
- Venue
- Antimicrobial Agents and Chemotherapy
- Publisher
- American Society for Microbiology
- Published
- 2006-11
- Volume
- 50
- Issue
- 11
- Pages
- 3839-3846
- ISSN
- 0066-4804 (ISSN-L)
- 1098-6596
- PMC
- PMC1635216
- OpenAlex
- W2135493487
- Cited by
- 521
- References
- 52
- Citations by year
- 2026: 26 · 2025: 29 · 2024: 20 · 2023: 20 · 2022: 20 · 2021: 39 · 2020: 33 · 2019: 21 · 2018: 22 · 2017: 41 · 2016: 34 · 2015: 39 · 2014: 25 · 2013: 31 · 2012: 26
- FWCI
- 9.91
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Antimicrobial Agents and Chemotherapy (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health
- Tufts University School of Medicine
- National Institute of General Medical Sciences (R01GM061162)
- National Institute of Allergy and Infectious Diseases (AI052805, R01AI052805)
- Topics
- Health Sciences › Medicine › Infectious Diseases › Antifungal resistance and susceptibility
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Fungal and yeast genetics research
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Bacterial biofilms and quorum sensing
- Keywords
- Candida albicans, biofilm, persister cells, antifungal tolerance, multidrug tolerance, amphotericin B, chlorhexidine, phenotypic variants, biofilm formation, cell attachment, dormancy, antifungal resistance
- MeSH terms
- Antifungal Agents, Candida albicans, Chlorhexidine, Disinfectants, Fluoresceins, Microbial Sensitivity Tests, Microscopy, Fluorescence, Phenotype, Biofilms, Drug Resistance, Multiple, Fungal
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