Healthcare-associated infections (HAIs) are caused by nosocomial pathogens. HAIs have an immense impact not only on developing countries but also on highly developed parts of world. They are predominantly device-associated infections that are caused by the planktonic form of microorganisms as well as those organized in biofilms. This review elucidates the impact of HAIs, focusing on device-associated infections such as central line-associated bloodstream infection including catheter infection, catheter-associated urinary tract infection, ventilator-associated pneumonia, and surgical site infections. The most relevant microorganisms are mentioned in terms of their frequency of infection on medical devices. Standard care bundles, conventional therapy, and novel approaches against device-associated infections are briefly mentioned as well. This review concisely summarizes relevant and up-to-date information on HAIs and HAI-associated microorganisms and also provides a description of several useful approaches for tackling HAIs.

Candida biofilm development can be influenced by diverse factors such as substrate, culture medium, carbohydrate source and pH. We have analysed biofilm formation of Candida albicans SC5314 and Candida glabrata ATCC 2001 wild-type strains in the presence of different media (RPMI 1640 versus YNB) and using different pH values (pH 5.6 or 7.0). We determined adhesion and biofilm formation on polystyrene, changes in the expression of adhesin genes during these processes and the susceptibility of mature biofilms to echinocandins. Biofilms formed on polystyrene by both Candida species proved to be influenced strongly by the composition of the medium rather than pH. C. albicans and C. glabrata formed thicker biofilms in RPMI 1640 medium, whereas in YNB medium, both species manifested adhesion rather than characteristic multilayer biofilm architecture. The stimulated biofilm formation in RPMI 1640 medium at pH 7.0 corroborated positively with increased expression of adhesin genes, essential to biofilm formation in vitro, including ALS3 and EAP1 in C. albicans and EPA6 in C. glabrata. The thicker biofilms grown in RPMI 1640 medium were more tolerant to caspofungin and anidulafungin than YNB-grown biofilms. We also observed that mature C. glabrata biofilms were less susceptible in RPMI 1640 medium to echinocandins than C. albicans biofilms. Environmental conditions, i.e. medium and pH, can significantly affect not only biofilm architecture, but also the expression profile of several genes involved during the different stages of biofilm development. In addition, growth conditions may also influence the antifungal-susceptibility profile of fungal populations within biofilm structures. Therefore, before designing any experimental biofilm set-up, it is important to consider the potential influence of external environmental factors on Candida biofilm development.

Device-associated microbial growth, including Candida biofilms, represents more than half of all human microbial infections and, despite a relatively small risk of implant-associated diseases, this type of infection usually leads to high morbidity, increased health-care costs and prolonged antimicrobial therapy. Animal models are needed to elucidate the complex host–pathogen interactions that occur during the development of attached and structured biofilm populations. We describe here a new in vivo model to study Candida biofilm, based on the avascular implantation of small catheters in rats. Polyurethane biomaterials challenged with Candida cells were placed underneath the skin of immunosuppressed animals following only minor surgery. The model allowed the study of up to ten biofilms at once, and the recovery of mature biofilms from 2 days after implantation. The adhering inoculum was adjusted to the standard threshold of positive diagnosis of fungal infection in materials recovered from patients. Wild-type biofilms were mainly formed of hyphal cells, and they were unevenly distributed across the catheter length as observed in infected materials in clinical cases. The hyphal multilayered structure of the biofilms of wild-type strains was observed by confocal microscopy and compared to the monolayer of yeast or hyphal cells of two well-known biofilm-deficient strains, efg1Δ/efg1Δ cph1Δ/cph1Δ and bcr1Δ/bcr1Δ, respectively. The subcutaneous Candida biofilm model relies on the use of implanted catheters with accessible, fast and minor surgery to the animals. This model can be used to characterize the ability of antimicrobial agents to eliminate biofilms, and to evaluate the prophylactic effect of antifungal drugs and biomaterial coatings.

In Europe, the mean incidence of urinary tract infections in intensive care units is 1.1 per 1000 patient‐days. Of these cases, catheter‐associated urinary tract infections (CAUTI) account for 98%. In total, CAUTI in hospitals is estimated to give additional health‐care costs of £1–2.5 billion in the United Kingdom alone. This is in sharp contrast to the low cost of urinary catheters and emphasizes the need for innovative products that reduce the incidence rate of CAUTI. Ureteral stents and other urinary‐tract devices suffer similar problems. Antimicrobial strategies are being developed, however, the evaluation of their efficacy is very challenging. This review aims to provide considerations and recommendations covering all relevant aspects of antimicrobial material testing, including surface characterization, biocompatibility, cytotoxicity, in vitro and in vivo tests, microbial strain selection, and hydrodynamic conditions, all in the perspective of complying to the complex pathology of device‐associated urinary tract infection. The recommendations should be on the basis of standard assays to be developed which would enable comparisons of results obtained in different research labs both in industry and in academia, as well as provide industry and academia with tools to assess the antimicrobial properties for urinary tract devices in a reliable way.

The pathogenic yeast Candida dubliniensis is phylogenetically very closely related to Candida albicans , and both species share many phenotypic and genetic characteristics. DNA fingerprinting using the species-specific probe Cd25 and sequence analysis of the internal transcribed spacer (ITS) region of the ribosomal gene cluster previously showed that C. dubliniensis is comprised of three major clades comprising four distinct ITS genotypes. Multilocus sequence typing (MLST) has been shown to be very useful for investigating the epidemiology and population biology of C. albicans and has identified many distinct major and minor clades. In the present study, we used MLST to investigate the population structure of C. dubliniensis for the first time. Combinations of 10 loci previously tested for MLST analysis of C. albicans were assessed for their discriminatory ability with 50 epidemiologically unrelated C. dubliniensis isolates from diverse geographic locations, including representative isolates from the previously identified three Cd25-defined major clades and the four ITS genotypes. Dendrograms created by using the unweighted pair group method with arithmetic averages that were generated using the data from all 10 loci revealed a population structure which supports that previously suggested by DNA fingerprinting and ITS genotyping. The MLST data revealed significantly less divergence within the C. dubliniensis population examined than within the C. albicans population. These findings show that MLST can be used as an informative alternative strategy for investigating the population structure of C. dubliniensis . On the basis of the highest number of genotypes per variable base, we recommend the following eight loci for MLST analysis of C. dubliniensis : Cd AAT1b , Cd ACC1 , Cd ADP1 , Cd MPIb , Cd RPN2 , Cd SYA1 , exCd VPS13 , and exCd ZWF1b , where “Cd” indicates C. dubliniensis and “ex” indicates extended sequence.

Summary: The expression of the ERG1, ERG3, ERG7, ERG9, ERG11 and ERG25 genes in response to incubation with fluconazole and biofilm formation was investigated using reverse‐transcription PCR and real‐time PCR in Candida albicans and Candida dubliniensis clinical isolates. The viability of biofilm was measured using an 2,3‐bis(2‐methoxy‐4‐nitro‐5‐sulfophenyl)‐2H‐tetrazolium‐5‐carboxanilide (XTT) reduction assay and confocal scanning laser microscopy (CSLM). Expression of the ERG11 gene was found to be low or moderate and it was regulated by fluconazole addition more so than by biofilm formation. Very low or non‐detectable expression of ERG1, ERG7 and ERG25 genes was detected in C. albicans. The expression of the ERG9 increased in the presence of fluconazole in some isolates. Following incubation with fluconazole, formation of biofilm by C. dubliniensis was coupled with up‐regulation of the ERG3 and ERG25 genes as have been observed previously in C. albicans. Planktonic cells of both Candida species released from biofilm displayed similar resistance mechanisms to fluconazole like attached cells. The XTT reduction assay and CSLM revealed that although incubation with fluconazole decreased the biofilm thickness, these were still comprised metabolically active cells able to disseminate and produce biofilm. Our data indicate that biofilm represents a highly adapted community reflecting the individuality of clinical isolates.