The DOI matches its Crossref record; 52 of the 52 references it cites were found in a registry or an index.
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.
Overview
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Verification
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“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]
The cited source says what the claim attributes to it.
In the citing paper
“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]
The cited source says what the claim attributes to it.
In the citing paper
“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]
The cited source says what the claim attributes to it.
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Citations
Cites
Bacterial Persistence as a Phenotypic Switch
Balaban, N. Q., Merrin, J., Chait, R., Kowalik, L., & Leibler, S. (2004) · Science · doi:10.1126/science.1099390 · Cited by 2,952
Chandra, J., Kuhn, D. M., Mukherjee, P. K., Hoyer, L. L., McCormick, T., & Ghannoum, M. A. (2001) · Journal of Bacteriology · doi:10.1128/jb.183.18.5385-5394.2001 · Cited by 1,578
Candida biofilms and their role in infection
Douglas, L. J. (2003) · Trends in Microbiology · doi:10.1016/s0966-842x(02)00002-1 · Cited by 1,150
Persister cells and tolerance to antimicrobials
Keren, I., Kaldalu, N., Spoering, A. L., Wang, Y., & Lewis, K. (2003) · FEMS Microbiology Letters · doi:10.1016/s0378-1097(03)00856-5 · Cited by 1,094
Self-citationCandida Infections of Medical Devices
Kojic, E. M., & Darouiche, R. O. (2004) · Clinical Microbiology Reviews · doi:10.1128/cmr.17.2.255-267.2004 · Cited by 1,055
Spoering, A. L., & Lewis, K. (2001) · Journal of Bacteriology · doi:10.1128/jb.183.23.6746-6751.2001 · Cited by 907
Self-citationSpecialized Persister Cells and the Mechanism of Multidrug Tolerance in Escherichia coli
Keren, I., Shah, D., Spoering, A. L., Kaldalu, N., & Lewis, K. (2004) · Journal of Bacteriology · doi:10.1128/jb.186.24.8172-8180.2004 · Cited by 848
Self-citationKuhn, D. M., George, T., Chandra, J., Mukherjee, P. K., & Ghannoum, M. A. (2002) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.46.6.1773-1780.2002 · Cited by 775
Standardized Method for In Vitro Antifungal Susceptibility Testing of Candida albicans Biofilms
Ramage, G., Vande Walle, K., Wickes, B. L., & López-Ribot, J. L. (2001) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.45.9.2475-2479.2001 · Cited by 753
Ramage, G., Saville, S. P., Thomas, D. P., & López-Ribot, J. L. (2005) · Eukaryotic Cell · doi:10.1128/ec.4.4.633-638.2005 · Cited by 678
Persisters: a distinct physiological state of E. coli
Khodursky, A. B., Zhang, Z., Devang, S., Kaldalu, N., Kurg, K., & Lewis, K. (2006) · Digital Repository Service (Northeastern University) · doi:10.1186/1471-2180-6-53 · Cited by 630
Self-citation“Sleeping Beauty”: Quiescence in Saccharomyces cerevisiae
Gray, J. V., Petsko, G. A., Johnston, G. C., Ringe, D., Singer, R. A., & Werner‐Washburne, M. (2004) · Microbiology and Molecular Biology Reviews · doi:10.1128/mmbr.68.2.187-206.2004 · Cited by 573
Mukherjee, P. K., Chandra, J., Kuhn, D. M., & Ghannoum, M. A. (2003) · Infection and Immunity · doi:10.1128/iai.71.8.4333-4340.2003 · Cited by 511
Comparison of Biofilms Formed byCandidaalbicansandCandidaparapsilosison Bioprosthetic Surfaces
Kuhn, D. M., Chandra, J., Mukherjee, P. K., & Ghannoum, M. A. (2002) · Infection and Immunity · doi:10.1128/iai.70.2.878-888.2002 · Cited by 485
A Dose-Response Study of Antibiotic Resistance in Pseudomonas aeruginosa Biofilms
Brooun, A., Liu, S., & Lewis, K. (2000) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.44.3.640-646.2000 · Cited by 474
Self-citationRamage, G. (2002) · Journal of Antimicrobial Chemotherapy · doi:10.1093/jac/dkf049 · Cited by 468
Regulation of Cell-Surface Genes and Biofilm Formation by the C. albicans Transcription Factor Bcr1p
Nobile, C. J., & Mitchell, A. P. (2005) · Current Biology · doi:10.1016/j.cub.2005.05.047 · Cited by 464
Baillie, G. S. (2000) · Journal of Antimicrobial Chemotherapy · doi:10.1093/jac/46.3.397 · Cited by 389
García-Sánchez, S., Aubert, S., Iraqui, I., Janbon, G., Ghigo, J.-M., & d'Enfert, C. (2004) · Eukaryotic Cell · doi:10.1128/ec.3.2.536-545.2004 · Cited by 353
Uses and Limitations of the XTT Assay in Studies of Candida Growth and Metabolism
Kuhn, D. M., Balkis, M. M., Chandra, J., Mukherjee, P. K., & Ghannoum, M. A. (2003) · Journal of Clinical Microbiology · doi:10.1128/jcm.41.1.506-508.2003 · Cited by 339
Ramage, G., VandeWalle, K., López-Ribot, J. L., & Wickes, B. L. (2002) · FEMS Microbiology Letters · doi:10.1016/s0378-1097(02)00853-4 · Cited by 334
Fungal Biofilms and Drug Resistance
Jabra-Rizk, M. A., Falkler, W. A., & Meiller, T. F. (2004) · Emerging Infectious Diseases · doi:10.3201/eid1001.030119 · Cited by 292
de Nobel, H., Ruiz, C., Martı́n, H., Morris, W. L., Brul, S., Molina, M., & Klis, F. M. (2000) · Microbiology · doi:10.1099/00221287-146-9-2121 · Cited by 269
ALTERNATIVECANDIDA ALBICANSLIFESTYLES: Growth on Surfaces
Kumamoto, C. A., & Vinces, M. D. (2005) · Annual Review of Microbiology · doi:10.1146/annurev.micro.59.030804.121034 · Cited by 247
Self-citationRamage, G., VandeWalle, K., Bachmann, S. P., Wickes, B. L., & Lopez-Ribot, J. L. (2002) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.46.11.3634-3636.2002 · Cited by 238
Vázquez‐Laslop, N., Lee, H., & Neyfakh, A. A. (2006) · Journal of Bacteriology · doi:10.1128/jb.188.10.3494-3497.2006 · Cited by 231
Ascospore Formation in the YeastSaccharomyces cerevisiae
Neiman, A. M. (2005) · Microbiology and Molecular Biology Reviews · doi:10.1128/mmbr.69.4.565-584.2005 · Cited by 226
MUKHERJEE, P., & Chandra, J. (2004) · Drug Resistance Updates · doi:10.1016/j.drup.2004.09.002 · Cited by 222
The biofilm glycocalyx as a resistance factor
Hoyle, B. D., Jaß, J., & Costerton, J. W. (1990) · Journal of Antimicrobial Chemotherapy · doi:10.1093/jac/26.1.1 · Cited by 219
Kumamoto, C. A. (2002) · Current Opinion in Microbiology · doi:10.1016/s1369-5274(02)00371-5 · Cited by 217
Self-citationA contact-activated kinase signals Candida albicans invasive growth and biofilm development
Kumamoto, C. A. (2005) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.0407097102 · Cited by 210
Self-citationCandida biofilms: antifungal resistance and emerging therapeutic options.
Kuhn, D. M., & Ghannoum, M. A. (2004) · PubMed · Cited by 168
Biofilms, Infection, and Antimicrobial Therapy
(2005) · CRC Press eBooks · doi:10.1201/9781420028232 · Cited by 168
Candida albicans Biofilm-Defective Mutants
Richard, M. L., Nobile, C. J., Bruno, V. M., & Mitchell, A. P. (2005) · Eukaryotic Cell · doi:10.1128/ec.4.8.1493-1502.2005 · Cited by 161
[48] Candida biofilms and their susceptibility to antifungal agents
Baillie, G. S., & Douglas, L. (1999) · Methods in enzymology on CD-ROM/Methods in enzymology · doi:10.1016/s0076-6879(99)10050-8 · Cited by 160
Candida biofilm: a well-designed protected environment
Mukherjee, P. K., Zhou, G., Munyon, R., & Ghannoum, M. A. (2005) · Medical Mycology · doi:10.1080/13693780500107554 · Cited by 149
New Aspects in the Molecular Basis of Polymer-Associated Infections due to Staphylococci
von Eiff, C., Heilmann, C., & Peters, G. (1999) · European Journal of Clinical Microbiology & Infectious Diseases · doi:10.1007/s100960050417 · Cited by 128
Candida albicans Biofilms: More Than Filamentation
Lopez-Ribot, J. L. (2005) · Current Biology · doi:10.1016/j.cub.2005.06.020 · Cited by 119
Biofilms of Candida albicans and their associated resistance to antifungal agents.
Ramage, G., Wickes, B. L., & Lopez-Ribot, J. L. (2001) · PubMed · Cited by 114
Adherence of Candida albicans to Silicone Induces Immediate Enhanced Tolerance to Fluconazole
Mateus, C., Crow, S. A., & Ahearn, D. G. (2004) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.48.9.3358-3366.2004 · Cited by 113
Effect of cell cycle position on thermotolerance in Saccharomyces cerevisiae
Plesset, J., Ludwig, J. R., Cox, B. S., & McLaughlin, C. S. (1987) · Journal of Bacteriology · doi:10.1128/jb.169.2.779-784.1987 · Cited by 111
Giusani, A. D., Vinces, M. D., & Kumamoto, C. A. (2002) · Genetics · doi:10.1093/genetics/160.4.1749 · Cited by 98
Self-citationBasrani, B. R. (2005) · Australian Endodontic Journal · doi:10.1111/j.1747-4477.2005.tb00221.x · Cited by 88
Théraud, M., Bédouin, Y., Guiguen, C., & Gangneux, J. (2004) · Journal of Medical Microbiology · doi:10.1099/jmm.0.05474-0 · Cited by 84
In Vitro Method To Study Antifungal Perfusion in Candida Biofilms
Samaranayake, Y. H., Ye, J., Yau, J. Y. Y., Cheung, B. P. K., & Samaranayake, L. P. (2005) · Journal of Clinical Microbiology · doi:10.1128/jcm.43.2.818-825.2005 · Cited by 83
Bagiński, M., Sternal, K., Czub, J., & Borowski, E. (2005) · Acta Biochimica Polonica · doi:10.18388/abp.2005_3426 · Cited by 82
Yeast cell death during DNA damage arrest is independent of caspase or reactive oxygen species
Wysocki, R., & Kron, S. J. (2004) · The Journal of Cell Biology · doi:10.1083/jcb.200405016 · Cited by 79
Martin, S. W., Douglas, L. M., & Konopka, J. B. (2005) · Eukaryotic Cell · doi:10.1128/ec.4.7.1191-1202.2005 · Cited by 69
Induction, Morphogenesis, and Germination of the Chlamydospore of Candida albicans
Jansons, V. K., & Nickerson, W. J. (1970) · Journal of Bacteriology · doi:10.1128/jb.104.2.910-921.1970 · Cited by 65
Marchetti, O., Moreillon, P., Entenza, J. M., Vouillamoz, J., Glauser, M. P., Billé, J., & Sanglard, D. (2003) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.47.5.1565-1570.2003 · Cited by 58
Persisters: Specialized Cells Responsible for Biofilm Tolerance to Antimicrobial Agents
Lewis, K., Spoering, A. L., Kaldalu, N., Keren, I., & Shah, D. (2005) · CRC Press eBooks · doi:10.1201/9781420028232-18 · Cited by 17
Self-citationLa caspofungine : du mécanisme d'action aux applications thérapeutiques
Datry, A., & Bart–Delabesse, E. (2005) · La Revue de Médecine Interne · doi:10.1016/j.revmed.2005.05.012 · Cited by 14
Flagged first, then by citations
Research works printed but not linked: 1
- 10.1111/j.1574-6968.2002.tb11330.x · DOI · Paper page
Cited by
Sorted by citations
Persister cells, dormancy and infectious disease
Lewis, K. (2007) · Nature Reviews Microbiology · doi:10.1038/nrmicro1557 · Cited by 2,052
Self-citationLewis, K. (2010) · Annual Review of Microbiology · doi:10.1146/annurev.micro.112408.134306 · Cited by 1,858
Self-citationSardi, J. C. O., Scorzoni, L., Bernardi, T., Fusco-Almeida, A. M., & Mendes Giannini, M. J. S. (2013) · Journal of Medical Microbiology · doi:10.1099/jmm.0.045054-0 · Cited by 1,184
Candida albicans Biofilms and Human Disease
Nobile, C. J., & Johnson, A. D. (2015) · Annual Review of Microbiology · doi:10.1146/annurev-micro-091014-104330 · Cited by 1,057
Essential Oils and Antifungal Activity
Nazzaro, F., Fratianni, F., Coppola, R., & Feo, V. D. (2017) · Pharmaceuticals · doi:10.3390/ph10040086 · Cited by 889
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
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
