Azole-resistant Candida can be a confounding factor for clinical management of opportunistic infections in immunocompromised patients, but rapid identification of such resistant organisms can improve patient outcome. New target-based molecular diagnostic strategies have the potential to identify resistant organisms faster than current culture-based assays. It was the objective of this study to determine whether target site mutations and/or drug pump over-expression are suitable surrogate markers of drug resistance that could aid new molecular-based diagnostic assays. A collection of 59 clinical isolates displaying a range of azole susceptibilities were assayed for mutations within the target gene Erg 11 and for over-expression of drug-efflux pumps Cdr 1, Cdr 2, Flu 1, and Mdr 1, as well as drug target gene Erg 11 by quantitative real-time PCR with molecular beacons. A fluconazole-resistant (MIC>or=64 microg/ml) phenotype was closely associated with over-expression of Cdr 1 (p=0.005), Cdr 2 (p=0.01), and Mdr 1 (p=0.03) along with four mutations in Erg 11 (T 229 A, Y 132 F, S 405 F, G 464 S). Changes in expression levels for Erg 11 and Flu 1 were not statistically correlated with resistance (p=0.27 and p=0.86, respectively). Overall, these findings provide a statistical basis to establish Erg 11 mutations and drug pump over-expression as surrogate markers for phenotypic fluconazole resistance.