What is the recommended dose of tigecycline (Tygacil) for treating infections?

Tigecycline Dosing Recommendations

The FDA-approved standard dose is 100 mg IV loading dose followed by 50 mg IV every 12 hours for most approved indications, but for severe infections—particularly pneumonia and multidrug-resistant organism infections—a high-dose regimen of 200 mg IV loading dose followed by 100 mg IV every 12 hours is strongly recommended to improve clinical outcomes. 1

Standard Dosing for Approved Indications

• For complicated skin and skin structure infections (cSSSI) and complicated intra-abdominal infections (cIAI): Use 100 mg IV loading dose, then 50 mg IV every 12 hours for 5-14 days 2
• For community-acquired bacterial pneumonia (CAP): Use 100 mg IV loading dose, then 50 mg IV every 12 hours for 7-14 days 2
• Infuse over 30-60 minutes every 12 hours 2
• No renal dose adjustment is required, even for patients on continuous renal replacement therapy 1

High-Dose Regimen for Severe Infections

For hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and severe multidrug-resistant infections, standard dosing is inadequate:

• Use 200 mg IV loading dose followed by 100 mg IV every 12 hours 1
• This high-dose regimen achieves 85% cure rates compared to only 69.6% with standard dosing 1, 3
• The rationale is that standard dosing achieves serum Cmax of only 0.87 mg/L and endothelial lining fluid concentrations of only 0.01-0.02 mg/L, which are insufficient for pulmonary and bloodstream infections 1, 3

Dosing for Multidrug-Resistant Organisms

For carbapenem-resistant Acinetobacter baumannii (CRAB):

• Use 100 mg IV loading dose, then 50 mg IV every 12 hours in combination with colistin PLUS sulbactam as triple therapy 1
• Duration: 7 days for pneumonia, 10-14 days for bloodstream infections 1
• Never use tigecycline monotherapy for CRAB pneumonia due to documented treatment failures 1
• Only use if MIC ≤2 mg/L 1

For carbapenem-resistant Enterobacterales (CRE):

• Use 100 mg IV loading dose, then 50 mg IV every 12 hours in combination with colistin or extended-infusion meropenem 1
• Duration: 7-14 days for bloodstream infections, 5-7 days for intra-abdominal infections 1

For vancomycin-resistant Enterococci (VRE) complicated intra-abdominal infections:

• Standard dosing is appropriate: 100 mg IV loading dose, then 50 mg IV every 12 hours for 5-7 days 1

Hepatic Impairment Dosing

• No adjustment needed for mild to moderate hepatic impairment (Child-Pugh A and B) 2
• For severe hepatic impairment (Child-Pugh C): Use 100 mg loading dose, then reduce maintenance to 25 mg IV every 12 hours 2
• Monitor these patients closely for treatment response 2

Critical Clinical Caveats

Tigecycline should NOT be used as monotherapy for bacteremia due to poor serum concentrations and documented poor outcomes 1, 3

Tigecycline is NOT indicated for:

• Hospital-acquired or ventilator-associated pneumonia (FDA contraindication due to increased mortality in clinical trials) 2
• Diabetic foot infections (failed to demonstrate non-inferiority) 2

Black Box Warning: An increase in all-cause mortality (0.6% risk difference) has been observed in meta-analyses; reserve tigecycline for situations when alternative treatments are not suitable 2

For severe infections with resistant pathogens, combination therapy is essential rather than monotherapy, particularly for CRAB and CRE infections 1, 3

Pediatric Dosing (Use Only When No Alternatives Available)

• Ages 8-11 years: 1.2 mg/kg IV every 12 hours (maximum 50 mg per dose) 2
• Ages 12-17 years: 50 mg IV every 12 hours 2
• Avoid use in pediatric patients unless absolutely no alternative antibacterial drugs are available due to increased mortality risk 2