Received: 8 September 2016 Revised: 20 September 2016 Accepted: 22 September 2016

DOI 10.1111/cmi.12674

MICROREVIEW

Polymicrobial infections involving clinically relevant

Gram‐negative bacteria and fungi
Sanjiveeni Dhamgaye1 | Yue Qu1,2 | Anton Y. Peleg1,2

1
Biomedicine Discovery Institute, Department
of Microbiology, Faculty of Medicine, Nursing Abstract
and Health Sciences, Monash University, Interactions between fungi and bacteria and their relevance to human health and disease have
Clayton, Victoria, Australia recently attracted increased attention in biomedical fields. Emerging evidence shows that bacteria
2
Department of Infectious Diseases, The and fungi can have synergistic or antagonistic interactions, each with important implications for
Alfred Hospital and Central Clinical School,
human colonization and disease. It is now appreciated that some of these interactions may be stra-
Monash University, Melbourne, Victoria,
Australia tegic and helps promote the survival of one or both microorganisms within the host. This review
Correspondence will shed light on clinically relevant interactions between fungi and Gram‐negative bacteria. Mech-
Anton Y. Peleg, Department of Infectious anism of interaction, host immune responses, and preventive measures will also be reviewed.
Diseases, Central Clinical School, The Alfred
Hospital and Monash University, Melbourne,
VIC 3004, Australia.
Email: anton.peleg@monash.edu

1 | I N T RO D U CT I O N
In their natural habitat, microorganisms often exist in close association
with a diversity of other species. These interactions drive evolutionary
development and adaptation in each microorganism, which promotes
the survival of the species within a given environmental or
host‐specific niche. To promote survival, the interactions between
microorganisms can either be synergistic or antagonistic and are often
mediated by metabolic factors, secretion of antimicrobial molecules, or
structural properties related to cell–cell interactions (Hogan & Kolter,
2002; Gaddy, Tomaras, & Actis, 2009; Gibson, Sood, & Hogan, 2009;
Peleg, Hogan, & Mylonakis, 2010). Within humans or in the natural
environment, microorganisms predominately live as biofilms, which
are complex three‐dimensional structures comprising of cell aggregates
encased within a self‐produced matrix of extracellular polymeric sub-
stances (Bjarnsholt et al., 2013; Flemming et al., 2016). In reality, these
biofilms are often polymicrobial (Partida‐Martinez, Monajembashi,
Greulich, & Hertweck, 2007). The focus of this review is on bacterial–
fungal interactions and infections involving human pathogens, more
specifically clinically relevant Gram‐negative bacteria. Developing an
understanding of how these microorganisms interact and how the host
immune system responds will help elucidate disease mechanisms and
uncover new insights for novel therapeutic or preventative strategies
(Kobayashi & Crouch, 2009).
Clinically, the role of polymicrobial infections on patient outcomes
remains poorly studied. With respect to Gram‐negative bacteria, the
most common sites for mixed‐species infections with fungi are the
respiratory tract, the gastrointestinal system, the skin, and the urinary
tract. This is predicted based on the resident microflora of these parts
of the human body and is now well supported by microbiome studies
of healthy humans. The human microbiome project recently analyzed
242 healthy human subjects and revealed that the signature microbes
of a particular niche differ greatly among individuals (Human
Microbiome Project, 2012). More recent studies have also focused
on fungal diversity in different parts of the body, also termed the
mycobiome (Ghannoum et al., 2010; Cui, Morris, & Ghedin, 2013).
These studies highlight the dominance of Candida albicans as a resident
fungus but also highlight the diversity in fungal species that may be
found in or on the human body including Malassezia, Cladosporium,
Aureobasidium, Saccharomycetales, Aspergillus, Fusarium, Alternaria,
Penicillium, and Cryptococcus (Ghannoum et al., 2010; Charlson et al.,
2012; Findley et al., 2013; Diaz, Strausbaugh, & Dongari‐Bagtzoglou,
2014; Goralska, 2014). These fungal species are ubiquitous in the envi-
ronment, and therefore, it is not surprising that they are found in
human body sites exposed to the environment (e.g., skin and respira-
tory tract). In a healthy human host, these fungi pose negligible risk
of acute disease, but when the host immune system is impaired in
some way such as post‐chemotherapy or transplant‐related immuno-
suppression, several of these fungi can become invasive and cause
serious infection. Of all the human fungal pathogens, the most com-
mon one that is in constant interaction with a diverse range of bacteria
is C. albicans. Hospitalized patients are often heavily colonized with
C. albicans at many body sites and Candida thrives off forming complex
biofilms on almost all medical devices, including mechanical ventilator

Cellular Microbiology 2016; 1–7 wileyonlinelibrary.com/journal/cmi © 2016 John Wiley & Sons Ltd 1
2 DHAMGAYE ET AL.

tubing used in the intensive care unit, vascular and urinary catheters,
and intra‐abdominal draining tubes (Kojic & Darouiche, 2004). Gram‐
negative bacteria also heavily populate these sites, and the mecha-
nisms and proposed impact of their interactions are discussed below
and shown in Figure 1.
2 | C L I N I C A L L Y I M P O R T A N T B A C T E R I A L–
FUNGAL INTERACTIONS
2.1 | C. albicans and Escherichia coli
E. coli is a Gram‐negative bacterium that specializes in transitioning
from a commensal to an opportunistic pathogen of humans. It is one
of the dominant bacterial species found in the gastrointestinal tract
of warm blooded animals (Tenaillon, Skurnik, Picard, & Denamur,
2010) and is one of the most common causes of urinary tract and
intra‐abdominal infections, and community‐acquired bloodstream
infections. Given that Candida is a commensal of the human gut, stud-
ies have assessed Candida–E. coli interactions in the context of perito-
nitis (Gale & Sandoval, 1957; Burd, Raymond, & Dunn, 1992; Akagawa,
Abe, & Yamaguchi, 1995; Klaerner et al., 1997; Ikeda, Suegara, Abe, &
Yamaguchi, 1999). Klaerner et al. showed that the interaction between
E. coli and C. albicans was synergistic and increased lethality in mice
when infected intraperitoneally compared to mono‐infection with
either microorganism (Klaerner et al., 1997). Similarly, in the urinary
tract, E. coli contributed to the establishment of C. albicans infection
in which C. albicans alone failed to cause infection due to its inability

FIGURE 1 Mechanisms and impact of Gram‐negative bacteria and fungal interaction I. Direct cell–cell contact: P. aeruginosa preferentially
attached to C. albicans hyphae forming biofilms on the filaments (Hogan & Kolter, 2002; Gibson et al., 2009) II. Facilitation of tissue attachment:
C. albicans attachment to the bladder mucosa is facilitated by the presence of E. coli (Levison & Pitsakis, 1987). III. Interaction through secretory
metabolites: (a) a feedback mechanism where phenazines from P. aeruginosa stimulate production of ethanol by C. albicans that subsequently
benefits P. aeruginosa (Chen et al., 2014). (b) Candida QS molecule, farnesol inhibits A. baumannii growth and viability (Peleg et al., 2008) and (c)
A. baumannii secretory factor and Pseudomonas QS molecule (C12‐acyl homoserine lactone) inhibits C. albicans yeast to hyphae transition (Cugini
et al., 2007; Gaddy et al., 2009)
DHAMGAYE ET AL.
to attach to the bladder mucosal lining (Levison & Pitsakis, 1987). The
mechanism was shown to be agglutination of C. albicans to the man-
nose‐binding E. coli, which facilitated the attachment of Candida to
the bladder mucosa (Figure 1; Levison & Pitsakis, 1987). It has also
been reported that E. coli positively modulates biofilm growth of
C. albicans in vitro, and this was due to bacterial lipopolysaccharide
(LPS; Bandara, Yau, Watt, Jin, & Samaranayake, 2009). The mechanism
by which E. coli LPS facilitates C. albicans biofilm growth is not known,
but a hypothesis is that it is secondary to LPS‐mediated glucocorticoid
production leading to immunosuppression (Besedovsky, del Rey,
Sorkin, & Dinarello, 1986; Chang, Feddersen, Henson, & Voelkel,
1987; Burd et al., 1992; Akagawa et al., 1995). Despite this positive
association between E. coli and C. albicans in the urinary tract, E. coli
negatively modulated the growth and biofilm formation of other
Candida species, including C. tropicalis, C. dubliniensis, C. krusei, and
C. parapsilosis (Bandara et al., 2009). Thus far, the clinical implications
of this antagonism in a biofilm setting remain unknown, but further
work is welcomed and may uncover relevant mechanisms that could
be exploited as future novel therapeutics.
2.2 | C. albicans and Pseudomonas aeruginosa
The respiratory tract and the skin are the major human body sites har-
boring interactions between C. albicans and P. aeruginosa. The clinical
impact of a polymicrobial infection involving these two microorgan-
isms has been studied in acute ventilator‐associated pneumonia
(VAP), as well as in chronic suppurative lung disease such as cystic
fibrosis. C. albicans has been frequently isolated from the airways of
patients on mechanical ventilatory support (Hamet et al., 2012) and
in general is clinically ignored. It has now been shown that Candida col-
onization of the respiratory tract may promote the development of
pseudomonal VAP and has been associated with the presence of
multidrug‐resistant bacteria (Azoulay et al., 2006; Hamet et al.,
2012). Furthermore, more severe clinical outcomes have been
observed in patients with VAP and cystic fibrosis infected with
P. aeruginosa and Candida spp. simultaneously, relative to P. aeruginosa
infection alone (Navarro et al., 2001; Hamet et al., 2012). These human
data have also been supported by findings from a rat pneumonia model
(Roux et al., 2009) and by another clinical study showing that antifun-
gal treatment can decrease the risk of developing P. aeruginosa infec-
tion in patients on mechanical ventilation (Nseir et al., 2007). These
studies highlight that Candida colonization in the airways may in itself
not cause disease, but it may be playing an underappreciated role in
facilitating bacterial infection.
Patients with burn wounds are also confronted with Candida–
P. aeruginosa co‐colonization and infection (Gupta, Haque,
Mukhopadhyay, Narayan, & Prasad, 2005). Clinical outcome data are
sparse in this area, but a previous study using a murine burn wound
infection model has shown that co‐infection led to greater mortality
than monomicrobial infection, and greater fungal burdens were
observed at the burn wound site and internal organs (Neely, Law, &
Holder, 1986).
The enhanced virulence observed with Candida–Pseudomonas co‐
infection may be partly explained by a recent proteomics study, which
found that when co‐cultured with C. albicans in mixed biofilms,
3
P. aeruginosa regulated its own production of various quorum‐sensing
(QS) molecules that consequentially induced the production of several
P. aeruginosa virulence factors including pyoverdine, rhamnolipids, and
pyocyanin (Trejo‐Hernandez, Andrade‐Dominguez, Hernandez, &
Encarnacion, 2014). There have now been several studies characteriz-
ing the complex mechanisms of interaction between Candida and
Pseudomonas (Peleg et al., 2010). These studies have shown both
antagonistic and synergistic interactions, depending on diverse envi-
ronmental factors, timing of interaction, and growth state at the time
of interaction. For example, co‐culturing P. aeruginosa and C. albicans
in liquid culture showed that P. aeruginosa preferentially adhered to
and formed biofilms on C. albicans hyphae rather than yeast cells,
and through the secretion of phospholipase C and phenazines, caused
hyphal death (Figure 1; Hogan & Kolter, 2002; Gibson et al., 2009). A
high concentration of phenazines triggered the production of toxic
reactive oxygen species that killed C. albicans hyphal cells (Hogan &
Kolter, 2002; Nseir et al., 2007; Morales et al., 2013). A lower concen-
tration of phenazines impaired hyphal growth of C. albicans and more
importantly switched fungal respiration to fermentation leading to
the production of ethanol, glycerol, and acetate by C. albicans in glu-
cose containing media (Morales et al., 2013). It was shown that
C. albicans ethanol production not only influenced biofilm maturation
but also promoted more phenazine production by P. aeruginosa
through WspR‐dependent activation of Pel exopolysaccharide (Chen
et al., 2014). The spectrum of P. aeruginosa phenazines produced was
in favor of those most effective against fungal cells and led to greater
production of ethanol by C. albicans, forming a feedback loop driving
the polymicrobial interaction towards the protection of P. aeruginosa
(Chen et al., 2014).
Other well‐studied molecular factors governing the interactions
between P. aeruginosa and C. albicans are their QS systems. QS mole-
cules play a crucial role in inter‐cellular communication within a given
population of cells, and there has been greater appreciation of their
cross‐kingdom impact. P. aeruginosa produces acyl homoserine lac-
tones, such as 3‐oxo‐C12‐homoserine lactone that inhibits the Ras1–
cyclic AMP–protein kinase A pathway required for hyphal growth in
C. albicans, thereby inhibiting filamentation of the fungus (Hogan,
Vik, & Kolter, 2004; Davis‐Hanna, Piispanen, Stateva, & Hogan,
2008; McAlester, O'Gara, & Morrissey, 2008). On the other hand,
C. albicans modulates P. aeruginosa biological activities through the
production of farnesol, a well‐known eukaryotic QS molecule. Cugini
et al. initially showed that farnesol produced by C. albicans reduced
the production of Pseudomonas quinolone signal and pyocyanin in
P. aeruginosa (Cugini, Calfee, Morales, Pesci, & Hogan, 2007). In a later
study, they reported that farnesol stimulated the production of Pseudo-
monas quinolone signal, N‐butanoyl‐L‐homoserine lactone and phena-
zine in P. aeruginosa when the growth environment changed from a
liquid culture to a colony biofilm grown on solid medium (Cugini,
Morales, & Hogan, 2010). The authors speculated that the varied
effects of farnesol on P. aeruginosa QS systems were associated with
different pathways it activated, either through interaction with specific
targets such as QS transcription factors (Cugini et al., 2007), or through
promoting the production of reactive oxygen species, which is linked
to the activation of P. aeruginosa QS systems (Cugini et al., 2010).
Overall, the laboratory studies characterizing the diverse interactions
4 DHAMGAYE
between Candida and Pseudomonas highlight the real complexities of
their interaction, and questions still remain as to how they apply during
human infection.
2.3 | C. albicans and Acinetobacter baumannii
A. baumannii has gained considerable importance as a multidrug‐resis-
tant, hospital‐associated pathogen (Howard, O'Donoghue, Feeney, &
Sleator, 2012). It has a particular predilection in causing infections in
patients in intensive care units, with VAP and bloodstream infection
being the most life‐threatening. A. baumannii is able to survive in the
hospital environment for prolonged periods of time, leading to prob-
lematic hospital outbreaks (Garnacho‐Montero et al., 2005).
A. baumannii interacts with fungal species, most importantly C. albicans,
in critically‐ill patients who are often on mechanical ventilation and
have vascular and urinary catheters in situ. The first descriptions of
A. baumannii–fungal interactions were with the model yeast Saccharo-
myces cerevisiae, where Acinetobacter was able to utilize ethanol pro-
duced by the yeast as a carbon source for improved growth (Smith,
Des Etages, & Snyder, 2004). Interestingly, these findings led to subse-
quent studies showing that ethanol mediated increased A. baumannii
resistance to salt stress, increased growth, virulence gene expression,
and virulence in multiple non‐mammalian infection model systems
(Smith et al., 2004; Smith et al., 2007; Camarena, Bruno, Euskirchen,
Poggio, & Snyder, 2010). In contrast, laboratory studies assessing inter-
actions between A. baumannii and C. albicans have demonstrated an
antagonistic relationship, whereby A. baumannii preferentially targets
the key virulence characteristic of C. albicans; hyphal development
(Peleg et al., 2008). The A. baumannii outer membrane protein was
implicated as a mechanism of attachment and killing of the filamentous
form of Candida by triggering apoptosis (Gaddy et al., 2009). However,
a secretory factor was also thought to be at play (Gaddy et al., 2009).
This polymicrobial interaction was also studied within the nematode
Caenorhabditis elegans, which showed that A. baumannii prevented
the morphological transition of C. albicans from a yeast to hyphal cell,
and this in turn led to reduced severity of disease (Peleg et al., 2008).
Conversely, when C. albicans was allowed to establish a mature biofilm
before co‐infection with A. baumannii, the growth of the bacteria was
impaired, and this was shown to be secondary to the secretion of the
Candida QS molecule farnesol (Peleg et al., 2008). Farnesol appears
to mediate its effect on A. baumannii by interfering with bacterial mem-
brane integrity (Kostoulias et al., 2016). Similar to the Candida–Pseudo-
monas interactions, the nature of Candida–A. baumannii interactions
are diverse and are determined by environmental conditions, initial
inoculum, and growth state of the individual microorganisms.
2.4 | Cryptococcus neoformans and Gram‐negative
bacteria
Apart from Candida, bacterial–fungal interactions with another yeast
known as C. neoformans have also been reported. C. neoformans is an
encapsulated soil fungus that is capable of infecting humans through
the respiratory tract. It is particularly dangerous in individuals with
impaired immunity, causing life‐threatening meningitis (Howard et al.,
2012). As a survival mechanism, C. neoformans synthesizes melanin
ET AL.
to protect itself from various environmental insults such as UV rays,
temperature shocks, predation by amoebae, and heavy metal toxicity
(Nosanchuk & Casadevall, 2003; Frases, Chaskes, Dadachova, &
Casadevall, 2006; Kronstad et al., 2012). Melanin production by
C. neoformans is normally dependent on an environmental precursor.
A remarkable interaction between C. neoformans and a Gram‐negative
bacterium, Klebsiella aerogenes, was observed in a laboratory setting
where C. neoformans was able to produce melanin by converting tyro-
sine to L‐3,4‐dihydroxyphenylalanine utilizing a bacterial enzyme dur-
ing combined growth (Frases et al., 2006). C. neoformans has also
been shown to interact with A. baumannii, whereby enhanced produc-
tion of the polysaccharide capsule was observed for certain serotypes
(Abdulkareem, Lee, Ahmadi, & Martinez, 2015). It would appear that
through evolution, C. neoformans has developed multiple strategies
for survival, including taking advantage of bacterial neighbors for
self‐preservation. However, the clinical implications of these findings
are not clear, as co‐infections with these Gram‐negative bacteria
would be extremely rare.
2.5 | Aspergillus fumigatus and Gram‐negative
bacteria
Apart from yeast–bacterial interactions, interactions with Aspergillus,
the most common mould pathogen of humans, have also been studied
(Brandl et al., 2011; Kwon‐Chung & Sugui, 2013). The clinical rele-
vance of these interactions predominately relates to the respiratory
tract and is especially evident in those with suppurative lung disease
such as patients with cystic fibrosis (Kwon‐Chung & Sugui, 2013).
In the context of cystic fibrosis, Aspergillus interacts with a multitude
of respiratory Gram‐negative bacteria, including P. aeruginosa,
Burkholderia cepacia complex, Stenotrophomonas maltophilia, and
Achromobacter spp. (Brandl et al., 2011; de Vrankrijker et al., 2011;
Hauser, Jain, Bar‐Meir, & McColley, 2011; Lambiase et al., 2011).
P. aeruginosa exerts an inhibitory effect on the establishment of
A. fumigatus biofilms by secreting a small diffusible heat‐stable mole-
cule (Mowat et al., 2010). The effect of this molecule however was
rendered ineffective once the biofilm was established. Notably, a
P. aeruginosa QS mutant did not show inhibitory effects on A. fumigatus
biofilm formation, indicating involvement of the QS system in the inhi-
bition, but further investigations are required to identify the exact mol-
ecule (Mowat et al., 2010). Whether these interactions impact on the
co‐existence of these microorganisms and the magnitude of lung
destruction in patients with cystic fibrosis remains to be determined.
3 | HOST IMMUNE RESPONSES TO
B A C TE R I A L – FU N G A L I N F E C T I O N S
Very little is known about host immune responses to polymicrobial
infections. It is clear that immune responses against bacteria or fungi
alone are dissimilar (Allard et al., 2009), but whether dual infection
stimulates both immune pathways or is dominated by one has only
recently been explored. In a mouse model to investigate lung adaptive
immune responses, fungal lysate alone from C. albicans and A. fumigatus
led to airway eosinophilia, release of TH2 type cytokines (IL‐4, IL‐5 and
DHAMGAYE ET AL.
IL‐13), and changes in mucus production, whereas bacterial antigens
from P. aeruginosa evoked an inflammatory response dominated by
neutrophils, secretion of TH1 type cytokines, and minimal mucus pro-
duction (Allard et al., 2009). Interestingly, co‐administration of bacte-
rial and fungal antigens activated immune responses characteristic of
bacteria alone, suggesting that at least in this mouse model, bacterial
antigens were able to immunomodulate the response towards fungal
antigens (Allard et al., 2009). How Pseudomonas antigens direct the
immune response towards fungal lysates from TH2 to TH1 is not
defined, but it appears to be independent of bacterial LPS and TLR4
(Allard et al., 2009). A subsequent report suggested that Candida can
also modulate the host immune response, which may promote
pseudomonal infection (Roux et al., 2009). Using a rat pneumonia
model, pre‐infection with Candida helped establish P. aeruginosa pneu-
monia by impairing reactive oxygen species generation by alveolar
macrophages (Roux et al., 2009). These studies highlight the potential
clinical implications of understanding how the host immune system
reacts to mixed bacterial–fungal infections and further studies may
provide important insights for the development of future preventative
or therapeutic strategies against polymicrobial infections.
4 | T RE A T M E NT A N D P R EV E N T A T I V E
S T R A T E G I E S A G A I N S T BA C T E R I A L –F U N G A L
INFECTIONS
Very little is known about the most effective antimicrobial treatment
of polymicrobial infections. Standard therapy includes use of conven-
tional antifungal and antibacterial agents based on antimicrobial
susceptibility results for individual microorganisms, but reports of
greater severity of illness, longer duration of symptoms, and greater
modification of treatment antimicrobials in polymicrobial infections
exist (Dyess, Garrison, & Fry, 1985; Tsai et al., 2014). Though
C. albicans was previously considered a colonizer in the respiratory
tract, it may actually play an important role in facilitating Gram‐
negative bacterial infection through protection within biofilms or alter-
ation of local host innate immune defenses. It is well established that
organisms are more resistant to antimicrobials in biofilms, and this
appears to be an even greater problem with polymicrobial biofilms
(Harriott & Noverr, 2009; Chotirmall et al., 2010; Filkins & O'Toole,
2015). The fungal scaffold may provide a shield for the interacting
bacteria, and therefore, combining a biofilm‐active antifungal with an
effective antibacterial may provide a potential therapeutic strategy for
these difficult infections (Qu et al., 2016).
Polymicrobial biofilms have been implicated in the pathogenesis of
cystic fibrosis and many hospital acquired infections related to
implanted medical devices such as central venous or urinary catheters
(Coad, Griesser, Peleg, & Traven, 2016). Developing effective and
durable medical surface‐attached antimicrobials that have activity
against Candida and Gram‐negative or –positive bacteria forms an
unmet clinical need. A recent example targeting the Candida biofilm
structure is the covalent surface attachment of the echinocandin
antifungal, caspofungin (Coad et al., 2015; Kucharikova et al., 2016).
These data hold promise for the prevention of the supporting Candida
biofilm structure that may be an important driver of polymicrobial
5
biofilm‐related infections. It will clearly take a combination of innova-
tive strategies to prevent the burgeoning problem of biofilm‐related
infections, in particular those that are polymicrobial (Salwiczek
et al., 2014).
5 | CO NC LUSIO NS
Although the seriousness and the impact of bacterial–fungal interac-
tions have been recognized globally, effective measures to deal with
the problem are lacking. From a mechanistic point of view, opportuni-
ties exist for identifying novel therapeutic strategies by exploiting the
ability of one microorganism to inhibit the growth and viability of
another. Also, new combination therapies and surface‐attached antimi-
crobials may help to target these interactions. Our understanding of
polymicrobial infections and their mechanisms of interaction are evolv-
ing, but it is clear that we still have a great deal to learn about this com-
plex and diverse problem.
ACKNOWLEDGMENT
A.Y.P was supported by an Australian National Health and Medical
Research Council Career Development Fellowship and Project Grant.
CONFLICTS OF INTERES T
The authors declare that they have no competing interests.
RE FE RE NC ES
Abdulkareem, A. F., Lee, H. H., Ahmadi, M., & Martinez, L. R. (2015). Fungal
serotype‐specific differences in bacterial–yeast interactions. Virulence,
6, 652–657.
Akagawa, G., Abe, S., & Yamaguchi, H. (1995). Mortality of Candida
albicans‐infected mice is facilitated by superinfection of Escherichia coli
or administration of its lipopolysaccharide. Journal of Infectious Diseases,
171, 1539–1544.
Allard, J. B., Rinaldi, L., Wargo, M. J., Allen, G., Akira, S., Uematsu, S., …
Whittaker, L. A. (2009). Th2 allergic immune response to inhaled fungal
antigens is modulated by TLR‐4‐independent bacterial products. Euro-
pean Journal of Immunology, 39, 776–788.
Azoulay, E., Timsit, J. F., Tafflet, M., de Lassence, A., Darmon, M., Zahar, J.
R., … Schlemmer, B. (2006). Candida colonization of the respiratory
tract and subsequent pseudomonas ventilator‐associated pneumonia.
Chest, 129, 110–117.
Bandara, H. M., Yau, J. Y., Watt, R. M., Jin, L. J., & Samaranayake, L. P.
(2009). Escherichia coli and its lipopolysaccharide modulate in vitro Can-
dida biofilm formation. Journal of Medical Microbiology, 58, 1623–1631.
Besedovsky, H., del Rey, A., Sorkin, E., & Dinarello, C. A. (1986). Immuno-
regulatory feedback between interleukin‐1 and glucocorticoid
hormones. Science, 233, 652–654.
Bjarnsholt, T., Alhede, M., Alhede, M., Eickhardt‐Sorensen, S. R., Moser, C.,
Kuhl, M., … Hoiby, N. (2013). The in vivo biofilm. Trends in Microbiology,
21, 466–474.
Brandl, M. T., Carter, M. Q., Parker, C. T., Chapman, M. R., Huynh, S., &
Zhou, Y. (2011). Salmonella biofilm formation on Aspergillus niger
involves cellulose–chitin interactions. PloS One, 6, e25553.
Burd, R. S., Raymond, C. S., & Dunn, D. L. (1992). Endotoxin promotes syn-
ergistic lethality during concurrent Escherichia coli and Candida albicans
infection. Journal of Surgical Research, 52, 537–542.
Camarena, L., Bruno, V., Euskirchen, G., Poggio, S., & Snyder, M. (2010).
Molecular mechanisms of ethanol‐induced pathogenesis revealed by
RNA‐sequencing. PLoS Pathogens, 6, e1000834.
6 DHAMGAYE
Chang, S. W., Feddersen, C. O., Henson, P. M., & Voelkel, N. F. (1987).
Platelet‐activating factor mediates hemodynamic changes and lung
injury in endotoxin‐treated rats. Journal of Clinical Investigation, 79,
1498–1509.
Charlson, E. S., Diamond, J. M., Bittinger, K., Fitzgerald, A. S., Yadav, A.,
Haas, A. R., … Collman, R. G. (2012). Lung‐enriched organisms and aber-
rant bacterial and fungal respiratory microbiota after lung transplant.
American Journal of Respiratory and Critical Care Medicine, 186, 536–
545.
Chen, A. I., Dolben, E. F., Okegbe, C., Harty, C. E., Golub, Y., Thao, S., …
Hogan, D. A. (2014). Candida albicans ethanol stimulates Pseudomonas
aeruginosa WspR‐controlled biofilm formation as part of a cyclic rela-
tionship involving phenazines. PLoS Pathogens, 10, e1004480.
Chotirmall, S. H., O'Donoghue, E., Bennett, K., Gunaratnam, C., O'Neill, S. J.,
& McElvaney, N. G. (2010). Sputum Candida albicans presages FEV(1)
decline and hospital‐treated exacerbations in cystic fibrosis. Chest,
138, 1186–1195.
Coad, B. R., Griesser, H. J., Peleg, A. Y., & Traven, A. (2016). Anti‐infective
surface coatings: Design and therapeutic promise against device‐
associated infections. PLoS Pathogens, 12, e1005598.
Coad, B. R., Lamont‐Friedrich, S. J., Gwynne, L., Jasieniak, M., Griesser, S. S.,
Traven, A., … Griesser, H. J. (2015). Surface coatings with covalently
attached caspofungin are effective in eliminating fungal pathogens.
Journal of Materials Chemistry B, 3, 8469–8476.
Cugini, C., Calfee, M. W., Farrow, J. M. III, Morales, D. K., Pesci, E. C., &
Hogan, D. A. (2007). Farnesol, a common sesquiterpene, inhibits PQS
production in Pseudomonas aeruginosa. Molecular Microbiology, 65,
896–906.
Cugini, C., Morales, D. K., & Hogan, D. A. (2010). Candida albicans‐produced
farnesol stimulates Pseudomonas quinolone signal production in
LasR‐defective Pseudomonas aeruginosa strains. Microbiology, 156,
3096–3107.
Cui, L., Morris, A., & Ghedin, E. (2013). The human mycobiome in health and
disease. Genome Medicine, 5, 63.
Davis‐Hanna, A., Piispanen, A. E., Stateva, L. I., & Hogan, D. A. (2008).
Farnesol and dodecanol effects on the Candida albicans Ras1‐cAMP
signalling pathway and the regulation of morphogenesis. Molecular
Microbiology, 67, 47–62.
de Vrankrijker, A. M., van der Ent, C. K., van Berkhout, F. T., Stellato, R. K.,
Willems, R. J., Bonten, M. J., & Wolfs, T. F. (2011). Aspergillus fumigatus
colonization in cystic fibrosis: Implications for lung function? Clinical
Microbiology and Infection, 17, 1381–1386.
Diaz, P. I., Strausbaugh, L. D., & Dongari‐Bagtzoglou, A. (2014). Fungal–
bacterial interactions and their relevance to oral health: Linking the
clinic and the bench. Frontiers in Cellular and Infection Microbiology, 4,
101.
Dyess, D. L., Garrison, R. N., & Fry, D. E. (1985). Candida sepsis. Implications
of polymicrobial blood‐borne infection. Archives of Surgery, 120,
345–348.
Filkins, L. M., & O'Toole, G. A. (2015). Cystic fibrosis lung infections:
Polymicrobial, complex, and hard to treat. PLoS Pathogens, 11,
e1005258.
Findley, K., Oh, J., Yang, J., Conlan, S., Deming, C., Meyer, J. A., … Segre, J.
A. (2013). Topographic diversity of fungal and bacterial communities in
human skin. Nature, 498, 367–370.
Flemming, H. C., Wingender, J., Szewzyk, U., Steinberg, P., Rice, S. A., &
Kjelleberg, S. (2016). Biofilms: An emergent form of bacterial life.
Nature Reviews: Microbiology, 14, 563–575.
Frases, S., Chaskes, S., Dadachova, E., & Casadevall, A. (2006). Induction by
Klebsiella aerogenes of a melanin‐like pigment in Cryptococcus
neoformans. Applied and Environmental Microbiology, 72, 1542–1550.
Gaddy, J. A., Tomaras, A. P., & Actis, L. A. (2009). The Acinetobacter
baumannii 19606 OmpA protein plays a role in biofilm formation on abi-
otic surfaces and in the interaction of this pathogen with eukaryotic
cells. Infection and Immunity, 77, 3150–3160.
ET AL.
Gale, D., & Sandoval, B. (1957). Response of mice to the inoculations of
both Candida albicans and Escherichia coli. I. The enhancement phenom-
enon. Journal of Bacteriology, 73, 616–624.
Garnacho‐Montero, J., Ortiz‐Leyba, C., Fernandez‐Hinojosa, E., Aldabo‐
Pallas, T., Cayuela, A., Marquez‐Vacaro, J. A., … Jimenez‐Jimenez, F. J.
(2005). Acinetobacter baumannii ventilator‐associated pneumonia: Epi-
demiological and clinical findings. Intensive Care Medicine, 31, 649–655.
Ghannoum, M. A., Jurevic, R. J., Mukherjee, P. K., Cui, F., Sikaroodi, M.,
Naqvi, A., & Gillevet, P. M. (2010). Characterization of the oral fungal
microbiome (mycobiome) in healthy individuals. PLoS Pathogens, 6,
e1000713.
Gibson, J., Sood, A., & Hogan, D. A. (2009). Pseudomonas aeruginosa‐
Candida albicans interactions: Localization and fungal toxicity of a
phenazine derivative. Applied and Environmental Microbiology, 75,
504–513.
Goralska, K. (2014). Interactions between potentially pathogenic fungi and
natural human microbiota. Annals of Parasitology, 60, 159–168.
Gupta, N., Haque, A., Mukhopadhyay, G., Narayan, R. P., & Prasad, R.
(2005). Interactions between bacteria and Candida in the burn wound.
Burns, 31, 375–378.
Hamet, M., Pavon, A., Dalle, F., Pechinot, A., Prin, S., Quenot, J. P., &
Charles, P. E. (2012). Candida spp. airway colonization could promote
antibiotic‐resistant bacteria selection in patients with suspected venti-
lator‐associated pneumonia. Intensive Care Medicine, 38, 1272–1279.
Harriott, M. M., & Noverr, M. C. (2009). Candida albicans and Staphylococ-
cus aureus form polymicrobial biofilms: Effects on antimicrobial
resistance. Antimicrobial Agents and Chemotherapy, 53, 3914–3922.
Hauser, A. R., Jain, M., Bar‐Meir, M., & McColley, S. A. (2011). Clinical sig-
nificance of microbial infection and adaptation in cystic fibrosis. Clinical
Microbiology Reviews, 24, 29–70.
Hogan, D. A., & Kolter, R. (2002). Pseudomonas–Candida interactions: An
ecological role for virulence factors. Science, 296, 2229–2232.
Hogan, D. A., Vik, A., & Kolter, R. (2004). A Pseudomonas aeruginosa
quorum‐sensing molecule influences Candida albicans morphology.
Molecular Microbiology, 54, 1212–1223.
Howard, A., O'Donoghue, M., Feeney, A., & Sleator, R. D. (2012).
Acinetobacter baumannii: An emerging opportunistic pathogen. Viru-
lence, 3, 243–250.
Human Microbiome Project, C (2012). Structure, function and diversity of
the healthy human microbiome. Nature, 486, 207–214.
Ikeda, T., Suegara, N., Abe, S., & Yamaguchi, H. (1999). Efficacy of
antibacterial drugs in mice with complex infection by Candida albicans
and Escherichia coli. Journal of Antibiotics, 52, 552–558.
Klaerner, H. G., Uknis, M. E., Acton, R. D., Dahlberg, P. S., Carlone‐Jambor,
C., & Dunn, D. L. (1997). Candida albicans and Escherichia coli are syner-
gistic pathogens during experimental microbial peritonitis. Journal of
Surgical Research, 70, 161–165.
Kobayashi, D. Y., & Crouch, J. A. (2009). Bacterial/Fungal interactions:
From pathogens to mutualistic endosymbionts. Annual Review of Phyto-
pathology, 47, 63–82.
Kojic, E. M., & Darouiche, R. O. (2004). Candida infections of medical
devices. Clinical Microbiology Reviews, 17, 255–267.
Kostoulias, X., Murray, G. L., Cerqueira, G. M., Kong, J. B., Bantun, F.,
Mylonakis, E., … Peleg, A. Y. (2016). Impact of a cross‐kingdom signaling
molecule of Candida albicans on Acinetobacter baumannii physiology.
Antimicrobial Agents and Chemotherapy, 60, 161–167.
Kronstad, J., Saikia, S., Nielson, E. D., Kretschmer, M., Jung, W., Hu, G., …
Attarian, R. (2012). Adaptation of Cryptococcus neoformans to mamma-
lian hosts: Integrated regulation of metabolism and virulence. Eukaryotic
Cell, 11, 109–118.
Kucharikova, S., Gerits, E., De Brucker, K., Braem, A., Ceh, K., Majdic, G., …
Thevissen, K. (2016). Covalent immobilization of antimicrobial agents
on titanium prevents Staphylococcus aureus and Candida albicans coloni-
zation and biofilm formation. Journal of Antimicrobial Chemotherapy, 71,
936–945.
DHAMGAYE ET AL.
Kwon‐Chung, K. J., & Sugui, J. A. (2013). Aspergillus fumigatus – what makes
the species a ubiquitous human fungal pathogen? PLoS Pathogens, 9,
e1003743.
Lambiase, A., Catania, M. R., Del Pezzo, M., Rossano, F., Terlizzi, V., Sepe,
A., & Raia, V. (2011). Achromobacter xylosoxidans respiratory tract infec-
tion in cystic fibrosis patients. European Journal of Clinical Microbiology
and Infectious Diseases, 30, 973–980.
Levison, M. E., & Pitsakis, P. G. (1987). Susceptibility to experimental Can-
dida albicans urinary tract infection in the rat. Journal of Infectious
Diseases, 155, 841–846.
McAlester, G., O'Gara, F., & Morrissey, J. P. (2008). Signal‐mediated inter-
actions between Pseudomonas aeruginosa and Candida albicans.
Journal of Medical Microbiology, 57, 563–569.
Morales, D. K., Grahl, N., Okegbe, C., Dietrich, L. E., Jacobs, N. J., & Hogan,
D. A. (2013). Control of Candida albicans metabolism and biofilm forma-
tion by Pseudomonas aeruginosa phenazines. MBio, 4, e00526–e00512.
Mowat, E., Rajendran, R., Williams, C., McCulloch, E., Jones, B., Lang, S., &
Ramage, G. (2010). Pseudomonas aeruginosa and their small diffusible
extracellular molecules inhibit Aspergillus fumigatus biofilm formation.
FEMS Microbiology Letters, 313, 96–102.
Navarro, J., Rainisio, M., Harms, H. K., Hodson, M. E., Koch, C., Mastella, G.,
… McKenzie, S. G. (2001). Factors associated with poor pulmonary
function: Cross‐sectional analysis of data from the ERCF. European Epi-
demiologic Registry of Cystic Fibrosis. European Respiratory Journal, 18,
298–305.
Neely, A. N., Law, E. J., & Holder, I. A. (1986). Increased susceptibility to
lethal Candida infections in burned mice preinfected with Pseudomonas
aeruginosa or pretreated with proteolytic enzymes. Infection and Immu-
nity, 52, 200–204.
Nosanchuk, J. D., & Casadevall, A. (2003). The contribution of melanin to
microbial pathogenesis. Cellular Microbiology, 5, 203–223.
Nseir, S., Jozefowicz, E., Cavestri, B., Sendid, B., Di Pompeo, C., Dewavrin,
F., … Durocher, A. (2007). Impact of antifungal treatment on Candida–
Pseudomonas interaction: A preliminary retrospective case–control
study. Intensive Care Medicine, 33, 137–142.
Partida‐Martinez, L. P., Monajembashi, S., Greulich, K. O., & Hertweck, C.
(2007). Endosymbiont‐dependent host reproduction maintains bacte-
rial‐fungal mutualism. Current Biology, 17, 773–777.
Peleg, A. Y., Hogan, D. A., & Mylonakis, E. (2010). Medically important bac-
terial–fungal interactions. Nature Reviews: Microbiology, 8, 340–349.
7
Peleg, A. Y., Tampakakis, E., Fuchs, B. B., Eliopoulos, G. M., Moellering, R. C.
Jr., & Mylonakis, E. (2008). Prokaryote–eukaryote interactions identi-
fied by using Caenorhabditis elegans. Proceedings of the National
Academy of Sciences of the United States of America, 105, 14585–14590.
Qu, Y., Locock, K., Verma‐Gaur, J., Hay, I. D., Meagher, L., & Traven, A.
(2016). Searching for new strategies against polymicrobial biofilm infec-
tions: Guanylated polymethacrylates kill mixed fungal/bacterial
biofilms. Journal of Antimicrobial Chemotherapy, 71, 413–421.
Roux, D., Gaudry, S., Dreyfuss, D., El‐Benna, J., de Prost, N., Denamur, E., …
Ricard, J. D. (2009). Candida albicans impairs macrophage function and
facilitates Pseudomonas aeruginosa pneumonia in rat. Critical Care Med-
icine, 37, 1062–1067.
Salwiczek, M., Qu, Y., Gardiner, J., Strugnell, R. A., Lithgow, T., McLean,
K. M., & Thissen, H. (2014). Emerging rules for effective antimicrobial
coatings. Trends in Biotechnology, 32, 82–90.
Smith, M. G., Des Etages, S. G., & Snyder, M. (2004). Microbial synergy via
an ethanol‐triggered pathway. Molecular and Cellular Biology, 24,
3874–3884.
Smith, M. G., Gianoulis, T. A., Pukatzki, S., Mekalanos, J. J., Ornston, L. N.,
Gerstein, M., & Snyder, M. (2007). New insights into Acinetobacter
baumannii pathogenesis revealed by high‐density pyrosequencing and
transposon mutagenesis. Genes and Development, 21, 601–614.
Tenaillon, O., Skurnik, D., Picard, B., & Denamur, E. (2010). The population
genetics of commensal Escherichia coli. Nature Reviews: Microbiology, 8,
207–217.
Trejo‐Hernandez, A., Andrade‐Dominguez, A., Hernandez, M., &
Encarnacion, S. (2014). Interspecies competition triggers virulence and
mutability in Candida albicans–Pseudomonas aeruginosa mixed biofilms.
The ISME Journal, 8, 1974–1988.
Tsai, M. H., Chu, S. M., Hsu, J. F., Lien, R., Huang, H. R., Chiang, M. C., …
Huang, Y. C. (2014). Polymicrobial bloodstream infection in neonates:
Microbiology, clinical characteristics, and risk factors. PloS One, 9,
e83082.
How to cite this article: Dhamgaye, S., Qu, Y., and Peleg, A. Y.
(2016), Polymicrobial infections involving clinically relevant
Gram‐negative bacteria and fungi, Cellular Microbiology, doi:
10.1111/cmi.12674