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Objectives : This study aimed to elucidate the relative involvement of drug resistance gene copy number and overexpression in fluconazole resistance in clinical  C. glabrata  isolates using a population-based approach.   Methods : Fluconazole resistance levels were quantified using the minimal inhibitory concentration (MIC) via Etest method. Both gene expression levels and gene copy number of  CgCDR1 ,  CgPDH1 ,  CgERG11 , and  CgSNQ2  were assessed via quantitative real-time PCR. The influence of the main effects and first-level interactions of both the expression level and copy number of these genes on fluconazole resistance levels were analyzed using a multivariate statistical model.   Results : Forty-three  C. glabrata  isolates were collected from 30 patients during in a hospital survey. In the multivariate analysis,  C. glabrata  fluconazole MICs were independently increased by  CgSNQ2  overexpression ( p  < 10 −4 ) and the interaction between  CgPDH1  gene copy number and  CgPDH1  expression level ( p  = 0.038). In contrast, both  CgPDH1  overexpression ( p  = 0.049) and the interaction between  CgSNQ2  and  CgERG11  expression ( p  = 0.003) led to a significant decrease in fluconazole MICs.   Conclusion : Fluconazole resistance in  C. glabrata  involves complex interactions between drug resistance gene expression and/or copy number. The population-based multivariate analysis highlighted the involvement of the  CgSNQ2  gene in fluconazole resistance and the complex effect of the other genes such as  PDH1  for which overexpression was associated with reduced fluconazole resistance levels, while the interaction between  PDH1  overexpression and copy number was associated with increased resistance levels.

Interactions between copy number and expression level of genes involved in fluconazole resistance in Candida glabrata