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 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
Standard Dosing for Approved Indications
The FDA-approved standard regimen is 100 mg IV loading dose followed by 50 mg IV every 12 hours for complicated skin and skin structure infections (cSSSI) and complicated intra-abdominal infections (cIAI) 1, 2
This standard dosing is appropriate when treating infections with tigecycline MIC ≤1 mg/L for cIAI and MIC ≤0.25 mg/L for cSSSI 3
No dose adjustment is required for renal impairment or continuous renal replacement therapy, as tigecycline is primarily eliminated through fecal excretion (59% of dose) rather than renal excretion (32% of dose) 1, 4
Dose reduction to 25 mg IV every 12 hours (after standard loading dose) is necessary only for severe hepatic impairment (Child-Pugh Class C) 5
High-Dose Regimen for Severe Infections
For hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and other severe infections, the high-dose regimen of 200 mg IV loading dose followed by 100 mg IV every 12 hours is strongly recommended due to significantly improved outcomes 6, 1, 7
Evidence Supporting Higher Dosing:
A randomized double-blind study demonstrated 85% cure rate with high-dose tigecycline (200 mg loading/100 mg q12h) compared to only 69.6% with standard dosing in VAP/HAP patients 6
Standard dosing achieves inadequate serum concentrations (Cmax only 0.87 mg/L) and extremely low endothelial lining fluid concentrations (0.01-0.02 mg/L), explaining poor outcomes in pulmonary infections 6, 1
For HAP with MIC ≤0.5 mg/L, standard dosing may be adequate, but increased dosing improves outcomes across broader MIC ranges 3
Specific Clinical Scenarios
Multidrug-Resistant Acinetobacter baumannii:
Standard dosing (100 mg loading/50 mg q12h) is appropriate only for approved indications (cSSSI, cIAI) when MIC ≤1 mg/L 6
For pulmonary or other non-approved indications, use high-dose regimen (200 mg loading/100 mg q12h) in combination with another active agent 6, 1
Tigecycline should never be used as monotherapy for A. baumannii infections outside approved indications due to uncertainties about efficacy 6
Carbapenem-Resistant Enterobacterales (CRE):
Use tigecycline in combination therapy with polymyxins or meropenem at 100 mg IV loading dose, then 50 mg IV q12h 1
For carbapenem-resistant Klebsiella pneumoniae, standard dosing achieves only 4.96-66.39% cumulative response, while increased dosing improves outcomes 3
Vancomycin-Resistant Enterococci (VRE):
- For complicated intra-abdominal infections: 50 mg IV q12h after 100 mg IV loading dose 1
Critical Clinical Caveats
Tigecycline should not be used as monotherapy for bacteremia due to poor serum concentrations with standard dosing and associated poor outcomes 1
For MDR organisms, combination therapy is strongly preferred over monotherapy regardless of dosing regimen 6, 1
Gram-positive bacteria are highly sensitive to tigecycline, while Gram-negative bacteria require careful MIC consideration and often benefit from increased dosing 3
The drug has a long elimination half-life (55.8 hours) and large volume of distribution (21.0 L/kg), supporting twice-daily dosing 4