Tigecycline Dosing Recommendations
For standard FDA-approved indications (complicated skin/skin structure infections and complicated intra-abdominal infections), use 100 mg IV loading dose followed by 50 mg IV every 12 hours for 5-14 days, but for severe infections—particularly pneumonia, bloodstream infections, or multidrug-resistant organisms—use high-dose tigecycline: 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, infused over 30-60 minutes. 2
- Duration is 5-14 days for complicated skin/skin structure infections and complicated intra-abdominal infections. 2
- For community-acquired pneumonia, treat for 7-14 days. 2, 3
- No renal dose adjustment is required, even in patients on continuous renal replacement therapy. 1
High-Dose Regimen for Severe Infections
For severe infections, particularly pulmonary infections, hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), or bloodstream infections, standard dosing is inadequate. 1, 4
- 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 for severe pulmonary infections. 1, 4
- Standard dosing achieves serum Cmax of only 0.87 mg/L, which is insufficient for bloodstream infections. 1
- Tigecycline concentrations in endothelial lining fluid are extremely low (0.01-0.02 mg/L) with standard dosing, explaining poor pulmonary efficacy. 1, 4
Dosing for Multidrug-Resistant Organisms
Carbapenem-Resistant Acinetobacter baumannii (CRAB)
- For CRAB pneumonia: 100 mg IV loading dose, then 50 mg IV every 12 hours PLUS colistin PLUS sulbactam as triple combination therapy for at least 7 days. 1
- For CRAB bloodstream infections: same dosing for 10-14 days. 1
- Never use tigecycline monotherapy for pneumonia—combination therapy is essential due to poor serum concentrations and documented treatment failures. 1, 4
- Only use if MIC ≤2 mg/L. 1
- For non-approved indications with CRAB, consider high-dose regimen (200 mg loading, then 100 mg every 12 hours) with combination therapy. 1
Carbapenem-Resistant Enterobacterales (CRE)
- For CRE bloodstream infections: 100 mg IV loading dose, then 50 mg IV every 12 hours in combination with colistin or meropenem (extended infusion) for 7-14 days. 1
- For CRE complicated intra-abdominal infections: 100 mg IV loading dose, then 50 mg IV every 12 hours for 5-7 days. 1
- Combination therapy with polymyxins or meropenem is preferred over monotherapy. 1, 4
Vancomycin-Resistant Enterococci (VRE)
- For VRE complicated intra-abdominal infections: 100 mg IV loading dose, then 50 mg IV every 12 hours for 5-7 days. 1, 4
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): 100 mg IV loading dose, then reduce maintenance dose to 25 mg IV every 12 hours. 2
- Monitor these patients closely for treatment response. 2
Critical Clinical Caveats
- Tigecycline should never be used as monotherapy for bacteremia due to poor outcomes with standard dosing. 1, 4
- For severe infections caused by resistant pathogens, combination therapy with another active agent is recommended over monotherapy. 1, 4
- Tigecycline should be positioned as a reserve agent for approved indications when patients have documented resistance to standard therapies, allergies/intolerances to multiple antibiotic classes, or infections caused by multidrug-resistant organisms. 4
- The drug has poor penetration into serum and endothelial lining fluid, limiting efficacy in bloodstream and pulmonary infections with standard dosing. 4