Tigecycline Dosing Recommendations
The standard FDA-approved tigecycline regimen is 100 mg IV loading dose followed by 50 mg IV every 12 hours, with no adjustment needed for renal impairment but a 50% dose reduction (to 25 mg every 12 hours) required for severe hepatic impairment (Child-Pugh C). 1, 2, 3, 4
Standard Adult Dosing
- Loading dose: 100 mg IV infused over 30-60 minutes 1, 2, 5, 4
- Maintenance dose: 50 mg IV every 12 hours 1, 2, 5, 4
- Duration: 5-14 days depending on infection type and clinical response 6, 4, 7
Renal Impairment Adjustments
No dose adjustment is required for any degree of renal impairment, including creatinine clearance <30 mL/min or patients on continuous renal replacement therapy. 2, 4 This is because tigecycline is eliminated primarily through biliary/fecal excretion (59%) rather than renal excretion (33%). 4
- Patients with severe renal failure can safely receive the standard 50 mg every 12 hours maintenance dose 8
- No supplemental dosing is needed after dialysis 2
Hepatic Impairment Adjustments
The dosing strategy differs significantly based on Child-Pugh classification:
- Child-Pugh A (mild): No adjustment needed; standard 50 mg every 12 hours 3, 4, 8
- Child-Pugh B (moderate): No adjustment needed; standard 50 mg every 12 hours 3, 4, 8
- Child-Pugh C (severe): Reduce maintenance dose by 50% to 25 mg IV every 12 hours (loading dose remains 100 mg) 1, 3, 4, 8
This reduction is necessary because tigecycline clearance decreases from 29.8 L/h in healthy subjects to 13.5 L/h in Child-Pugh C patients. 3
Pediatric Dosing (Ages ≥8 Years)
Tigecycline should be avoided in all pediatric patients unless no alternative antibiotics are available, due to increased mortality risk and potential for permanent tooth discoloration in children under 8 years. 9
If absolutely necessary:
- Ages 8-11 years: 1.2 mg/kg IV every 12 hours (maximum 50 mg per dose) 1, 9, 5
- Ages 12-18 years: 100 mg IV loading dose, then 50 mg IV every 12 hours (adult dosing) 1, 9, 5
- Under 8 years: Contraindicated due to risk of permanent tooth discoloration 1, 9
High-Dose Regimen for Severe Infections
For severe infections, particularly hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), or carbapenem-resistant Enterobacterales (CRE) bloodstream infections:
- Loading dose: 200 mg IV 2
- Maintenance dose: 100 mg IV every 12 hours 2
- This high-dose regimen achieved 85% cure rate versus 69.6% with standard dosing and significantly reduced mortality (OR 0.44,95% CI 0.30-0.66) 2
Critical Clinical Pitfalls
Never use tigecycline as monotherapy for bacteremia or pneumonia due to poor serum concentrations (Cmax only 0.87 mg/L with standard dosing) and documented treatment failures. 2 Combination therapy with colistin, meropenem, or sulbactam is essential for multidrug-resistant organisms. 2
- Avoid for urinary tract infections: Tigecycline achieves inadequate urinary concentrations despite tissue penetration due to large volume of distribution (7-9 L/kg) 2, 9, 4
- Monitor coagulation: Tigecycline prolongs PT and aPTT 1, 9, 5
- Gastrointestinal effects are common: Nausea (28.5%), vomiting (19.4%), and diarrhea (11.6%) occur frequently 4, 7
- Monitor liver function: Elevated LFTs can occur 1
- Watch for metabolic effects: Hypoglycemia and hypoproteinemia have been reported 1, 9
Preparation and Administration
- Reconstitute 50 mg vial with 5.3 mL of 0.9% sodium chloride or 5% dextrose to achieve 10 mg/mL concentration 5
- Further dilute to final concentration of 1 mg/mL in 100 mL of 0.9% sodium chloride or 5% dextrose 5
- Infuse over 30-60 minutes 5, 4