Antimicrobial drug resistance can limit the ability to effectively treat patients. Numerous factors have been proposed to impact the development of antimicrobial resistance, including those specific to the drug and the dosing regimen. The field of investigation that examines the relationship between dosing regimen and outcome is termed antimicrobial pharmacokinetics and pharmacodynamics. Our prior in vivo investigations examined the relationship between fluconazole pharmacodynamics and the modulation of isogenic resistant and susceptible Candida albicans populations in a mixed-inoculum design (1). The goal of the current studies was to examine the impact of fluconazole pharmacodynamics on resistance emergence from a susceptible parent population over time using a murine systemic-candidiasis model. Both microbiologic and transcriptional endpoints were examined during the evolution of cell populations. As in our previous investigation, the more frequently administered dosing regimen prevented the emergence of a resistant cell phenotype. Conversely, dosing regimens that produced prolonged sub-MIC concentrations were associated with resistance development. The studies also demonstrated a striking relationship between fluconazole pharmacodynamic exposures and the mRNA abundance of drug resistance-associated efflux pumps. Global transcriptional profiling of cell populations during the progressive emergence of a resistance phenotype provides insight into the mechanisms underlying this complex physiologic process.Antimicrobial resistance has become an increasingly serious public health problem in a wide range of infectious diseases (5,15,24,26,34,42,47,48). Thus, it is imperative to understand the factors that lead to the evolution of resistance and to design strategies to prevent or delay the emergence of antimicrobial-resistant pathogens.It is well accepted that antimicrobial exposure is correlated with the prevalence of antimicrobial resistance (7,8,13,16,17,19,21). However, the relationship in the context of use pattern and resistance development is complex and remains for the most part undefined. A recent study examined these relationships for the fungistatic triazole antifungal fluconazole in an in vivo candidiasis model (1). The experimental model utilized isogenic strain pairs of Candida albicans in which the parent population was fluconazole susceptible and the other isolate was drug resistant. The treatment studies examined modulation of the resistant and susceptible cell populations from an initial inoculum consisting of a small percentage of the less susceptible group of cells. Study of the relationship between fluconazole pharmacokinetics and amplification of each cell population was undertaken with six strain pairs. Fluconazole dosing regimens producing prolonged sub-MIC exposures or a brief period of time in which drug concentrations exceeded the MIC (%T Ͼ MIC) resulted in the selection of resistant cells in each of the experiments.The current studies further examined the relationship between the dose lev...