Tigecycline, a derivative of the tetracycline minocycline, is the first available glycylcycline. Tigecycline inhibits protein synthesis by binding to the 30S ribosomal subunit. It is bacteriostatic.

Tigecycline is given IV. Tigecycline has a large volume of distribution (> 12 L/kg), penetrating well into bone, lung, liver, and kidney tissues. A half-life of 36 h should provide for once/day dosing. Most of the drug is excreted in bile and feces.

Indications

Tigecycline is effective against many resistant bacteria, including those with resistance to tetracyclines. Tigecycline is active against

• Many gram-positive bacteria, including methicillin-susceptible and methicillin-resistant Staphylococcus aureus, Streptococcus pneumoniae with reduced penicillin sensitivity, vancomycin-sensitive Enterococcus faecalis, vancomycin-resistant E. faecium,and Listeria sp
• Many gram-negative bacteria, such as multidrug-resistant Acinetobacter baumannii, Stenotrophomonas maltophilia, Haemophilus influenzae, and most Enterobacteriaceae (including some strains that produce extended-spectrum β-lactamases [ESBLs] and other strains that were carbapenem-resistant based on production of a carbapenemase or metallo-β-lactamase)
• Many atypical respiratory pathogens (chlamydiae, Mycoplasma sp), Mycobacterium abscessus, M. fortuitum, and anaerobes, including Bacteroides fragilis, Clostridium perfringens, and C. difficile

It is not effective against Pseudomonas aeruginosa, Providencia sp, Morganella morganii, or Proteus sp.

Tigecycline is indicated for complicated skin and soft-tissue infections and complicated intra-abdominal infections, but the drug shows promise for other infections as well. Clinically, tigecycline is used mainly for the following:

• Complicated intra-abdominal infections, including abscesses, appendicitis, cholecystitis, diverticulitis, perforations, and peritonitis
• Complicated skin and soft-tissue infections, including abscesses and infected burns or ulcers
• Community-acquired bacterial pneumonia caused by S. pneumoniae (penicillin-susceptible isolates), including cases with concurrent bacteremia, H. influenzae (β-lactamase negative isolates), and Legionella pneumophila
• Ventilator-associated hospital-acquired pneumonia due to multidrug resistant pathogens

Contraindications

Tigecycline is contraindicated in patients who have had an allergic reaction to it and in children ≤ 8 yr.

Use During Pregnancy and Breastfeeding

Tigecycline is in pregnancy category D (there is evidence of human risk, but clinical benefits may outweigh risk); it, like tetracyclines, can affect fetal bones and teeth.

Whether tigecycline enters breast milk and is safe to use during breastfeeding is unknown.

Adverse Effects

Adverse effects include

• Nausea, vomiting, and diarrhea
• Photosensitivity
• Hepatotoxicity

Nausea and vomiting are common. Increases in serum amylase, total bilirubin concentration, PT, and transaminases can occur in patients treated with tigecycline. Isolated cases of significant hepatic dysfunction and hepatic failure have been reported in patients being treated with tigecycline. Many of tigecycline's adverse effects are similar to those of tetracyclines (eg, photosensitivity).

Dosing Considerations

Dose is adjusted in patients with hepatic dysfunction but not in those with renal dysfunction. Serum levels of warfarin may increase, but INR does not appear to increase.

Last full review/revision July 2009 by Matthew E. Levison, MD