多重耐药鲍曼不动杆菌的感染性心内膜炎患者围术期抗凝与抗感染药物治疗管理与评价

Management and evaluation of postoperative anticoagulant and anti-infective in a patient with multidrug resistant Acinetobacter baumannii infective endocarditis

目的通过评价1例多重耐药鲍曼不动杆菌(MDRAB)的感染性心内膜炎患者瓣膜置换围术期抗凝与抗感染药物治疗,探讨临床药师参与MDRAB感染性心内膜炎患者药学服务模式及作用。方法通过1例MDRAB感染性心内膜炎治疗案例,结合相关文献及报道,从瓣膜置换术前、术中及术后抗凝治疗、感染性心内膜炎抗感染药物的选择、疗程及用法用量、药学监护等方面切入,协助医师制订和完善治疗方案,并对患者进行用药教育。结果患者瓣膜置换术后第1日开始口服华法林2.5 mg,维持INR值在1.8～2.3;临床药师根据病原菌结果协助医师制订阿米卡星800 mg ivgtt qd联合头孢哌酮钠/舒巴坦钠注射剂(2∶1)3 g ivgtt q6 h抗感染方案,经过6周抗感染治疗后痊愈出院。结论临床药师在整个治疗过程,利用药学知识提供药学服务,提高临床药物治疗的水平,为患者提供安全、有效的药学服务。

Objective To evaluate the postoperative anticoagulant and anti-infection therapy in a patient with multidrug resistant Acinetobacter baumannii(MDRAB)infective endocarditis,and to explore the mode of pharmaceutical care and the role of clinical pharmacists.Methods We combined related guidelines and pharmaceutical care for a patient with MDRAB infective endocarditis,discussed the anticoagulant therapy before,during and after the valve replacement,the choice of anti-infective drugs for infective endocarditis,the course of treatment,dosage and usage of drugs,pharmaceutical care and so on,to assist physicians in formulating and improving the treatment scheme.Besides,medicine education materials were timely provided to the patient before being discharged from the hospital.Results Warfarin 2.5 mg was administered on the first day after the valve replacement,and the INR value was maintained at 1.8-2.3.According to the results of pathogenic bacteria,clinical pharmacists assisted physician in the formulation of anti-infection program[Amikacin 800 mg ivgtt qd combined with Cefoperazone sodium/sulbactam injection(2∶1)3 g ivgtt q6 h].After 6 weeks of anti-infective treatment,the patient was cured and discharged from hospital.Conclusion Clinical pharmacists can fully make use of their pharmaceutical knowledge to provide pharmaceutical care for patients with MDRAB infective endocarditis,and help develop a safe and effective treatment.