**High oral bioavailability – consider switching IV to PO when taking PO**
- CrCl < 50 mL/min: Consider 50% reduction in normal dose
- Dialysis (HD): Standard load; maintenance doses post-HD on HD days
CVVHD
Fluconazole has paradoxically increased clearance in CRRT
- Normal dose 100 mg Q24h: 200 mg Q24h
- Normal dose 200 mg Q24h: 400 mg Q24h
- Normal dose 400 mg Q24h: 800 mg load, then 400 mg Q12h
- Normal dose 800 mg Q24h: 1.2 g load, then 400 mg Q8h (1.2 g/day)
Notes
- CRRT recommendations are based on data for ≤ 3L/hr
- For CRRT > 3L/hr page Infectious Diseases Pharmacy
(RRMC p99917; SMH p91059)