Tigecycline Dosing Recommendations
For standard approved indications (complicated skin/soft tissue and intra-abdominal infections), use 100 mg IV loading dose followed by 50 mg IV every 12 hours, but for severe infections—particularly hospital-acquired pneumonia, ventilator-associated pneumonia, or multidrug-resistant organisms—use the high-dose regimen of 200 mg IV loading dose followed by 100 mg IV every 12 hours. 1, 2
Standard Dosing for Approved Indications
The FDA-approved standard regimen is 100 mg IV loading dose, then 50 mg IV every 12 hours for complicated skin and skin structure infections (cSSSI) and complicated intra-abdominal infections (cIAI), administered over 30-60 minutes 3
Treatment duration is typically 5-14 days for cSSSI and cIAI, and 7-14 days for community-acquired pneumonia (CAP), guided by clinical response 3
No renal dose adjustment is required, even in patients on continuous renal replacement therapy, as tigecycline is primarily eliminated via feces (59%) with only 32% renal excretion 3, 4
High-Dose Regimen for Severe Infections
For severe infections, particularly pulmonary infections, the high-dose regimen achieves significantly better outcomes:
Use 200 mg IV loading dose followed by 100 mg IV every 12 hours for hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and severe multidrug-resistant infections 1, 2
This high-dose regimen achieved 85% cure rate compared to only 69.6% with standard dosing in severe infections 1
The rationale for higher dosing in pulmonary infections is that tigecycline achieves very low concentrations in endothelial lining fluid (0.01-0.02 mg/L) with standard dosing, explaining inferior outcomes in VAP 5, 1
Hepatic Impairment Dosing
No adjustment needed for mild to moderate hepatic impairment (Child-Pugh A and B) 3
For severe hepatic impairment (Child-Pugh C): use 100 mg loading dose, then reduce maintenance dose to 25 mg IV every 12 hours 3
Monitor these patients closely for treatment response and adverse effects 3
Pathogen-Specific Considerations
For Acinetobacter baumannii infections:
Standard dosing (50 mg q12h) is appropriate for approved indications if MIC ≤1 mg/L 5, 1
For non-approved indications (especially pulmonary infections), use the high-dose regimen (200 mg loading, then 100 mg q12h) 5, 1
Always use combination therapy with another active agent when treating severe A. baumannii infections, as monotherapy has uncertain efficacy 5, 2
For carbapenem-resistant Enterobacterales (CRE):
Use tigecycline in combination with polymyxins or meropenem at standard dosing (100 mg loading, then 50 mg q12h) 1
Consider high-dose regimen for severe infections, as standard dosing achieves only 4.96-66.39% cumulative response for CRKP 6
Critical Clinical Caveats
Avoid tigecycline in these situations:
Do not use for bacteremia as monotherapy due to poor serum concentrations (Cmax only 0.87 mg/L with standard dosing) 1
Not indicated for hospital-acquired or ventilator-associated pneumonia per FDA labeling due to increased mortality in comparative trials, though high-dose regimens may be considered when no alternatives exist 3
Not indicated for diabetic foot infections due to failed non-inferiority trial 3
Reserve tigecycline for situations when alternative treatments are not suitable due to 0.6% increased all-cause mortality risk observed in meta-analysis 3
Important pharmacokinetic considerations:
Tigecycline has a long half-life (55.8 hours) and large volume of distribution (21.0 L/kg), explaining its extensive tissue penetration but low serum levels 4
The drug undergoes minimal metabolism, with unchanged tigecycline being the predominant compound in serum, urine, and feces 4
No significant drug interactions via cytochrome P-450 system 7