Fungal Biofilm-Related Diseases: Diagnosis, Treatment, and Emerging Challenges
Professor Gordon Ramage, BSc, PhD, discusses the increasing impact of fungal biofilms, new treatment options, and the need for enhanced detection methods.
Fungal biofilm-related diseases are becoming more common due to increased use of implanted medical devices, immunosuppressants, and an aging population. The WHO has classified many fungi as critical or high-priority organisms due to their ability to form biofilms. These biofilms, which consist of interconnected cells on surfaces like catheters or within sinuses, pose challenges in diagnosis and treatment. They are difficult to detect, remove, and resistant to most antifungal agents, leading to higher risks for patients, including morbidity, mortality, surgeries, and extended hospital stays. Understanding biofilm formation mechanisms is key to improving diagnostic and therapeutic approaches.
In our interview with Gordon Ramage, BSc, PhD, a professor of infection prevention and control at Glasgow Caledonian University, we discussed the concern surrounding fungal biofilms and the challenges clinicians face when diagnosing and treating these infections.
Ramage explained the challenge of diagnosing and treating fungal biofilms, "Fungal biofilms are very difficult to differentiate from bacterial biofilms," he said. "Clinically, the signs—such as elevated temperature and other clinical parameters—are often indistinguishable. So, we don’t really know if someone has a fungal biofilm unless we can see it directly or have a definitive diagnostic test."
The Role of Medical Devices and Immunosuppressants
The rising incidence of fungal biofilm-related diseases can be attributed to the increased use of implanted medical devices and the use of immunosuppressants. “Fungi tend to affect people who are more immunocompromised. So, if you're on immunosuppressants, the likelihood of fungal pathogens growing on a surface is increased," Ramage said. "With the growing use of implanted medical devices globally, each new device presents an opportunity for a pathogen. So, when you're immunocompromised and have an implanted device, the likelihood of fungal biofilm formation increases."
Therapeutic Strategies
When asked about the most promising therapeutic strategies for fungal biofilms, Ramage highlighted a few existing treatments and emerging drugs. "Drugs like liposomal Amphotericin B and the echinocandins have been shown to be useful, and they’re already used in clinical practice." He also pointed to newer antifungal drugs in development, "Drugs like Abrex, Fungoz, Resfungi, a new echinocandin, and Fim. These drugs are currently in Phase 2 and Phase 3 trials. From a biofilm perspective, they’ve shown effectiveness, particularly in lab settings."
Importance of Better Detection and Diagnosis
Ramage also discussed the importance of improving detection methods for fungal biofilms, "Diagnostics take time and money, and for some patients, it’s hard to respond quickly. Ideally, you would remove a device, then perhaps use microscopy or other forms of diagnostics like galactomannan or beta-glucan testing. But these methods are inherently expensive and may not provide more useful information than existing diagnostics."
"The approach is different depending on the type of biofilm," he said. "For example, in implanted devices, the device can be removed. But with conditions like vulvovaginal candidiasis or wound infections, the situation is more complex."
As fungal pathogens continue to emerge as a global threat, Ramage shared insights on the growing body of research in this area, noting that the article he co-authored is the culmination of years of work. "This article is probably the culmination of 25 years of work, starting when I was a postdoc in the United States," he explained. "There’s a lot of work being done in this field, and what we’re seeing now is that more and more fungal pathogens are being identified. Candida is a prime example—we didn’t really know much about it until 2009."
Ramage also highlighted the role of hospital environments in the spread of fungal infections. "It’s highly transmissible and can persist on surfaces," he said. "So, it’s not just about biofilms being on the person, it’s about the immediate surroundings, like the hospital environment, which is where a lot of the interest lies."
Future Directions for Research and Treatment
Looking ahead, Ramage expressed concern over the increasing prevalence of fungal infections, particularly in immunocompromised and elderly patients. "The more opportunities they have—such as in elderly patients or those who are immunocompromised—the more we’re going to see interesting things happen," he warned. "Unfortunately, those things aren’t necessarily good, but we will see more and more of them. We need to be mindful of that."
On the topic of antifungal drug development, he said "A lot of antifungal drug development is based on mycology. We take yeast cells or spores in low concentrations, test them against an antifungal, and say, 'Well, that’s sensitive,'" he explained. "But what we need to remember is that when we think about these organisms growing on surfaces—on a device, on a wound, or around a hospital—they’re not individual cells anymore. So, we should be thinking about developing biocides and new antifungals with this in mind, recognizing that, in some cases, these organisms form biofilms."
