Resistance of Candida albicans against the widely used antifungal agent fluconazole is often due to active drug efflux from the cells. In many fluconazole-resistant C. albicans isolates the reduced intracellular drug accumulation correlates with constitutive strong expression of the MDR1 gene, encoding a membrane transport protein of the major facilitator superfamily that is not detectably expressed in vitro in fluconazole-susceptible isolates. To elucidate the molecular changes responsible for MDR1 activation, two pairs of matched fluconazole-susceptible and resistant isolates in which drug resistance coincided with stable MDR1 activation were analyzed. Sequence analysis of the MDR1 regulatory region did not reveal any promoter mutations in the resistant isolates that might account for the altered expression of the gene. To test for a possible involvement of trans-regulatory factors, a GFP reporter gene was placed under the control of the MDR1 promoter from the fluconazole-susceptible C. albicans strain CAI4, which does not express the MDR1 gene in vitro. This MDR1P-GFP fusion was integrated into the genome of the clinical C. albicans isolates with the help of the dominant selection marker MPA R developed for the transformation of C. albicans wild-type strains. Integration was targeted to an ectopic locus such that no recombination between the heterologous and resident MDR1 promoters occurred. The transformants of the two resistant isolates exhibited a fluorescent phenotype, whereas transformants of the corresponding susceptible isolates did not express the GFP gene. These results demonstrate that the MDR1 promoter was activated by a trans-regulatory factor that was mutated in fluconazoleresistant isolates, resulting in deregulated, constitutive MDR1 expression.Candida albicans is an important opportunistic fungal pathogen of humans and is the major cause of oropharyngeal candidiasis (OPC) in patients with AIDS (21). The azole antifungal agent fluconazole is a widely used compound to treat OPC. In recent years, however, the incidence of treatment failures has been rising. Especially in patients with AIDS who have recurrent OPC and who are receiving prolonged fluconazole therapy, treatment failures are due to the emergence of fluconazole-resistant strains (10, 22). Resistant C. albicans isolates frequently exhibit reduced intracellular drug accumulation that correlates with enhanced expression of certain multiple drug resistance genes, the ATP-binding cassette (ABC) transporters CDR1 and CDR2, and the major facilitator MDR1 (8,14,24,25,29). Fluconazole resistance is usually a stable phenotype that is maintained in the absence of selection pressure by the drug. This implies that genetic alterations have occurred in the resistant isolates that result in a constitutive overexpression of the drug efflux pumps. The MDR1 gene is not detectably expressed in vitro in fluconazole-susceptible C. albicans isolates but is strongly activated in many strains after the development of fluconazole resistance. The molecular chang...