INTRODUCTION
The human microbiota is composed of a diverse array of bacterial and fungal species that colonize different sites in the body (
1,
2). Although the composition and function of the bacteria in the microbiota have been extensively studied (
3–7), the mycobiota, or fungal members of the microbiome, remains largely understudied (
1). In the gastrointestinal tract, shotgun sequencing revealed that fungi comprise approximately 0.1% of the microorganisms (
8,
9), yet this is likely an underrepresentation (
1). Some of the most common fungi in the human body are
Candida spp., which colonize mucosal surfaces such as the oral cavity, gastrointestinal (GI) tract, urogenital tract, and also the skin in approximately 70% of healthy individuals (
10). An expansion in the
Candida population may lead to mucosal and deep tissue infections (candidiasis), while disseminated candidiasis (candidemia) often affects patients on broad-spectrum antibiotics or antifungal drugs, patients with chronic inflammation, nosocomial patients, and patients that are immunocompromised, such as those with HIV or AIDS (
11,
12). Not surprisingly,
Candida is the fourth leading cause of nosocomial infections, and candidemia mortality rates may be as high as 50% (
13–15).
Of the various
Candida spp., the opportunistic pathogens
Candida albicans and
Candida glabrata account for roughly 60% of
Candida spp. in the human body.
C. albicans is often the leading cause of candidiasis and candidemia, with
C. glabrata frequently reported as the second most common
Candida isolate in infections within North America (
13,
16–18).
C. albicans and
C. glabrata are often coisolated together during an infection, and the isolation of a single species,
C. glabrata, from infection sites is rare (
19). Additionally, the coisolation of
C. albicans and
C. glabrata has been linked to increased pathogenesis, as the occurrence of coisolation was reported in almost 80% of patients with severe inflammation (
20). The inherent resistance of
C. glabrata against commonly used antifungals such as fluconazole and amphotericin B is generally higher than that of
C. albicans (
21,
22). The abundances of
C. glabrata and non-
albicans Candida species have been shown to increase in a clinical study during a course of antifungal treatment against
Candida spp. (
13). Nguyen et al. (
16) observed 427 nosocomial patients with candidemia and found that after treatment with amphotericin B,
C. glabrata was the most common non-
albicans Candida species to cause candidemia, mainly due to the persistence of
C. glabrata and its resistance to antifungal treatment (
16).
Biofilm communities provide a protective niche for microorganisms from stress and external perturbations, and it is estimated that 65% to 80% of human infections originate from biofilms (
23). Fungal species such as
Candida are also found in polymicrobial biofilms in the human body and are generally more resistant to antifungal agents than when present in suspension (
24). It has also been shown that the biofilm microenvironment facilitates
Candida in evading the host immune system and persisting in the body (
25,
26).
Candida albicans not only resides in the biofilm but also contributes to its development, as it is also capable of forming robust biofilms (
27,
28). This is primarily due to its polymorphic nature, as it is able to grow as yeast, pseudohyphae, and hyphae. The hyphal morphology of
C. albicans is associated with an increased virulence, as it enables the active penetration of mucosal surfaces into host tissue, which can lead to disseminated candidiasis. On the other hand,
C. glabrata mainly grows as a budding yeast and has been shown to attach to hyphae of
C. albicans to invade tissue (
29). The presence of
Candida spp. in a polymicrobial biofilm not only promotes its virulence but also increases the biofilm formation and antimicrobial resistance of other pathogenic bacteria, as has been demonstrated for
Staphylococcus aureus (
30).
Despite the synergism between
C. albicans and
C. glabrata, there is limited information on the underlying mechanisms involved in the interaction between the two fungal species and their effects on virulence and invasion. Recent work by Pathak et al. with
C. albicans and
C. glabrata cocultures demonstrated that cocultures with a 1:1 initial ratio of
C. albicans to
C. glabrata yielded the highest biofilm biomass over any other
Candida species combination as well as over single-species biofilms (
31). In addition, a recent host microbiome study showed that the abundances of fungal species, including
C. albicans, changed with diet and potentially contributed to disease (
32); thus, it is conceivable that the relative abundance of a fungal species within a polymicrobial biofilm can impact pathogenesis. However, there is little knowledge regarding the relative abundance of each species in a biofilm and how that contributes to biofilm formation and pathogenesis. In this work, we investigated the effect of how changing the initial
C. albicans and
C. glabrata ratio impacts biofilm formation and structure and antifungal drug susceptibility.
DISCUSSION
Recent microbiome studies have started to shed light on how the composition of bacterial and fungal species can potentially correlate with health and disease (
32,
42–44).
Candida, being a commensal fungal microorganism and opportunistic pathogen (
10), is involved in this paradigm of health and disease. As
Candida species exhibit variable susceptibility to antifungal treatments, a changing prevalence of
Candida spp. in candidiasis and candidemia on an epidemiological level (
45–47) and changing colonization of fungal species over time at the single patient level have been observed (
45,
48,
49), suggesting there are changes in the mycobiome during the course of disease and treatment.
Candida biofilms pose a high risk to human health, as high rates of infection and mortality are correlated with biofilm formation due to the enhanced resistance to antimicrobials (
50). Clinical studies show that
C. albicans and
C. glabrata are often coisolated in infections (
45,
51,
52), and the degree of infection is worsened by the presence of both species (
20,
53). While the clinical importance of
Candida spp. in biofilms is evident, the interactions between
C. albicans and
C. glabrata, in terms of their relative abundances and their effects on the development of
Candida biofilms, are poorly understood. In this work, we investigated the impacts of changing the relative starting ratios of
C. albicans and
C. glabrata in coculture biofilms on biofilm formation and the resistance to antifungal treatment. Our results clearly demonstrate that the relative abundance of each species has a significant impact on biofilm formation, as biofilms increased with increased levels of
C. glabrata. This observation is especially interesting as we and others (
54–57) have shown that
C. glabrata in monocultures forms a weaker biofilm than
C. albicans. The fact that this density-dependent effect was observed with biofilms grown on different surfaces (glass, polystyrene, and acrylic) suggests that this behavior is independent of the surface characteristics.
An analysis of biofilms using CLSM revealed that the ratios of
C. albicans to
C. glabrata remained relatively constant at the levels in which they were seeded over the duration of the experiment. This suggests that one species did not have a nutritional or metabolic advantage to outgrow the other in the biofilm (see Fig. S3 in the supplemental material). Cataldi et al. (
58) demonstrated that a complex biofilm structure (biofilm composed of blastospores and pseudohyphal and hyphal cells) increased the biofilm cell surface area, which can increase adhesion to host cell surfaces and pathogenesis. Recently, Alonso et al. demonstrated that macrophage migration toward
C. albicans, a mechanism for clearing infection and pathogens in the human body, is reduced 2-fold when cells are in a biofilm, which was attributed to increased biofilm thickness and structure (extracellular matrix encasement of yeast and hyphal cells [
59]), rather than the composition of the biofilm matrix (
60). In this work, we also observed increased structural complexity and heterogeneity in coculture
Candida biofilms compared to those of monoculture biofilms, where the highest biofilm heterogeneity was seen in the
C. albicans/
C. glabrata 1:3 biofilm. The increase in structural complexity was evident from the increase in
C. albicans hypha formation and uneven thickness across the biofilm, which resulted in a larger network of cells and more complex 3D structure (
Fig. 2 and
3; Fig. S5 to S7).
Because of the increase in hyphae and uneven topology, the overall biofilm thickness was not an appropriate metric for quantifying coculture
Candida biofilms. Instead, 3D biofilm reconstructed images were used for biofilm data interpretation. For example, the increase in hypha length observed with the 1:3
C. albicans/
C. glabrata biofilms suggests that the
C. albicans/
C. glabrata 1:3 biofilm is potentially more virulent than 1:1 or 3:1 ratio biofilms, as an increase in hypha length is often associated with increased
C. albicans virulence (
34). We observed that a majority of
C. albicans yeast cells were on the bottom of the biofilm with hyphal cells growing upward (
Fig. 2; Fig. S7), which is similar to the observations reported by Kuhn et al. with monoculture
C. albicans biofilms (
61). In our observations of
C. albicans/
C. glabrata coculture biofilms,
C. glabrata was evenly dispersed throughout the biofilm, and aggregates formed around
C. albicans hyphae (
Fig. 3C and
4). While clustering of
C. glabrata around
C. albicans hyphae was seen in all three
C. albicans/
C. glabrata ratios (
Fig. 4A to
C), maximal clustering was observed in the
C. albicans/
C. glabrata 1:3 biofilm. This observation is consistent with the longer hyphae that were observed in this coculture condition (
Fig. 3B).
Previous studies have shown that several
C. albicans genes (e.g.,
HWP1 and
ALS3) and
C. glabrata genes (e.g.,
EPA1 and
EPA6) are involved in increased adhesion and biofilm formation
in vitro and
in vivo (
37,
39,
40). In this study, the expression of both
HWP1 and
ALS3 increased in the coculture biofilms compared to that in a
C. albicans monoculture biofilm, and the highest fold induction was observed with the starting ratio of
C. albicans to
C. glabrata of 1:3 (
Table 2). The increase in
HWP1 gene expression for the
C. albicans/
C. glabrata 1:3 biofilm is consistent with the increased hypha length seen in the biofilms (
Fig. 3B), as
HWP1 (hyphal wall protein 1) is a
C. albicans hypha-associated gene involved in adhesion and invasion (
62,
63).
ALS3 gene expression was highest in
C. albicans/
C. glabrata 1:3 coculture biofilms compared to that in
C. albicans monoculture biofilms at 6 and 24 h, indicating that Als3 may be needed for the initial formation of
Candida coculture biofilms (at 6 h) and also for the maintenance of a mature biofilm structure (at 24 h). Early activation of
ALS3 gene expression in
C. albicans biofilms was previously demonstrated by Nailis et al., where
ALS3 gene expression increases within 6 h compared to that in planktonic cells and then is downregulated after 48 h (
64). The increased expression of
C. albicans cell wall adhesins
HWP1 and
ALS3 also suggests an increase in the attachment of cells within the biofilm, which enables more robust biofilm formation than in biofilms with lower adhesin expression. Moreover, increased hyphae in
C. albicans and increased
HWP1 expression are associated with increased yeast-hypha cell interactions in the biofilm, which contributes to the increased structural complexity of cells within the biofilm matrix (
Fig. 4D), and
ALS3 has been demonstrated to facilitate the binding of
C. glabrata to
C. albicans in a biofilm, further leading to biofilm robustness and thickness in coculture (
29). The expression of
HWP1 and
ALS3 is also activated earlier on in the
C. albicans/
C. glabrata 1:3 biofilm than in the
C. albicans monoculture, indicating an earlier initiation of biofilm formation, which possibly contributes to the higher biomass seen over time with the 1:3 ratio.
We observed an increase in the expression of the
C. glabrata adhesion gene
EPA1 at 24 h in coculture biofilms. Recently, Tati et al. demonstrated that several
EPA adhesions genes (
EPA8 and
EPA19) are upregulated in mixed-species cultures of
C. albicans and
C. glabrata (
29). While no significant change in the expression of
EPA1 or
EPA6 was observed between coculture and monoculture biofilms (
Table 3), it should be noted that
EPA1 has been primarily reported to be involved in adhesion to host tissue (
40), and the lack of an observed gene expression change in
EPA1 and
EPA6 could also be the result of subtelomeric silencing (
65–67).
In concordance with the biofilm data,
C. albicans/
C. glabrata 1:3 coculture biofilms exhibited the highest resistance to caspofungin treatment (
Fig. 5). Cataldi et al. (
58) reported that a nonuniform biofilm has an increased susceptibility to antifungal drugs due to a lower biofilm cell-matrix density and discontinuous cell embedding in the extracellular matrix, which could explain the increased resistance to caspofungin with the
C. albicans/
C. glabrata 1:3 biofilm. Interestingly, while
C. albicans monoculture biofilms were more susceptible to caspofungin,
C. glabrata biofilm cells in coculture grew in the presence of 0.03 μg/ml caspofungin (Fig. S3). It is unclear why
C. glabrata cell viability increases in coculture biofilms in the presence of caspofungin and whether this phenomenon is observed for other antifungal drugs as well.
Our study presents multiple lines of evidence to demonstrate that the initial relative cell densities of C. albicans and C. glabrata in a coculture biofilm strongly influence the extent of biofilm formation as well as its structural complexity. The increased hypha length in the C. albicans/C. glabrata 1:3 biofilm contributes to a more complex biofilm structure, which increases the thickness and antifungal resistance of the biofilm. Additionally, increased hyphae also provide more hyphal surface area for C. glabrata yeast cells to attach and cluster in the biofilm. These observations suggest that the changing Candida polymicrobial culture dynamics during biofilm formation may alter the course of the infection. Ongoing work in our laboratory is focused on investigating the transcriptomic changes in coculture biofilms and identifying the molecular basis underlying Candida interspecies interactions.