Context Candida-related infections are nowadays a serious Public Health Problem emerging multidrug-resistant strains. Candida biofilm also leads bloodstream infections to invasive systemic infections. Objective The present meta-analysis aimed to analyze Candida biofilm rate, type, and antifungal resistance among hospitalized patients between 1995 and 2020. Data sources Web of Science, Scopus, PubMed, and Google Scholar databases were searched for English papers using the following medical subject heading terms (MESH): “invasive candidiasis”; “bloodstream infections”; “biofilm formation”; “biofilm-related infections”; “mortality”; and “prevalence”. Study selection The major inclusion criteria included reporting the rate of biofilm formation and the prevalence of biofilm-related to Candida species, including observational studies (more exactly, cohort, retrospective, and case-control studies). Furthermore, data regarding the mortality rate, the geographical location of the study set, and the use of anti-fungal agents in clinical isolates were also extracted from the studies. Data extraction Independent extraction of articles by 2 authors using predefined data fields, including study quality indicators. Data synthesis A total of 31 studies from publicly available databases met our inclusion criteria. The biofilm formation in the data set varied greatly from 16 to 100% in blood samples. Most of the studies belonged to Europe (17/31) and Asia (9/31). Forest plot showed a pooled rate of biofilm formation of 80.0% (CI: 67–90), with high heterogeneity (Q = 2567.45, I2 = 98.83, τ2 = 0.150) in random effects model (p < 0.001). The funnel plot and Egger’s linear regression test failed to find publication bias (p = 0.896). The mortality rate in Candida-related bloodstream infections was 37.9% of which 70.0% were from biofilm-associated infections. Furthermore, Candida isolates were also characterized in low, intermediate, or high biofilm formers through their level of biofilm mass (crystal violet staining or XTT assays) after a 24h growth. When comparing between countries, statistical differences were obtained (p = 0.0074), showing the lower and higher biofilm prevalence values in Italy and Spain, respectively. The prevalence of low, intermediate, and high biofilms were 36.2, 18.9, and 35.0% (p < 0.0001), respectively. C. tropicalis was the prevalent species in high biofilm formation (67.5%) showing statistically significant differences when compared to other Candida species, except for C. krusei and C. glabrata. Finally, the rates of antifungal resistance to fluconazole, voriconazole, and caspofungin related to biofilm were 70.5, 67.9 and 72.8% (p < 0.001), respectively. Conclusions Early detection of biofilms and a better characterization of Candida spp. bloodstream infections should be considered, which eventually will help preserve public health resources and ultimately diminish mortality among patients.

Candida tropicalis is an emergent pathogen with a high rate of mortality associated with its biofilm formation. Biofilm formation has important repercussions on the public health system. However, little is still known about its biofilm life cycle. The present study analyzed the biofilm life cycle of Candida albicans and C. tropicalis during various timepoints (24, 48, 72, and 96 h) through biomass assays, colony-forming unit (CFU) counting, and epifluorescence and scanning electron microscopies. Our results showed a significant difference between C. albicans and C. tropicalis biofilms in each biomass and viability assay. All-time samples in the biomass and viability assays confirmed statistical differences between the Candida species through pairwise Wilcoxon tests (p &lt; 0.05). C. albicans demonstrated a lower biomass growth but reached nearly the same level of C. tropicalis biomass at 96 h, while the CFU counting assays exhibited a superior number of viable cells within the C. tropicalis biofilm. Statistical differences were also found between C. albicans and C. tropicalis biofilms from 48- and 72-h microscopies, demonstrating C. tropicalis with a higher number of total cells within biofilms and C. albicans cells with a superior cell area and higher matrix production. Therefore, the present study proved the higher biofilm production of C. tropicalis.