From the FDA Drug Label
The pharmacokinetic profile of tigecycline was not significantly altered in any of the renally impaired patient groups, nor was tigecycline removed by hemodialysis. No dosage adjustment of tigecycline is necessary in patients with renal impairment or in patients undergoing hemodialysis
For a patient with Pantoea agglomerans infection that is resistant to all antibiotics and also has impaired renal function, the available treatment option is:
- Tigecycline: No dosage adjustment is necessary in patients with renal impairment or in patients undergoing hemodialysis 1. However, it is crucial to note that the effectiveness of tigecycline against Pantoea agglomerans is not directly addressed in the provided drug label. Therefore, the use of tigecycline for this specific infection should be approached with caution.
From the Research
For a patient with kidney failure and Pantoea agglomerans resistant to all antibiotics, I strongly recommend consultation with infectious disease specialists and nephrologists immediately to discuss the best course of treatment, which may include combination antibiotic therapy with dose adjustments for renal impairment. The treatment options for such a patient are limited and challenging due to the resistance to all antibiotics and the presence of kidney failure. Key considerations in managing this patient include:
- Combination antibiotic therapy with dose adjustments for renal impairment, possibly using colistin (1-2.5 mg/kg/day divided doses, adjusted for renal function) or tigecycline (100 mg loading dose, then 50 mg every 12 hours) as suggested in the example answer, but the most recent study 2 suggests that all patients responded well to intravenous antibiotics.
- Source control through drainage of any abscesses or removal of infected devices is crucial, as seen in the study 2 where only two patients required the removal of the tunneled catheter.
- Supportive care should include careful fluid management, electrolyte monitoring, and possibly temporary dialysis if needed, considering the patient's kidney failure.
- The patient requires close monitoring of renal function with regular blood tests, as kidney failure complicates antibiotic selection due to the need for dose adjustments or contraindications related to nephrotoxicity risks. Pantoea agglomerans is an opportunistic gram-negative bacterium that can cause serious infections in immunocompromised hosts, and pan-resistant strains are particularly challenging to treat, as highlighted in the study 3 where three patients died due to carbapenem-resistant P. agglomerans. The most recent and highest quality study 2 provides valuable insights into the treatment of Pantoea agglomerans infections in patients with kidney failure, emphasizing the importance of prompt treatment, source identification, and early implementation of preventive strategies.