临床药师参与胆道术后伴发多药耐药铜绿假单胞菌感染的药学监护

Pharmaceutical care for biliary tract surgery associated with multidrug-resistant Pseudomonas aeruginosa infections

目的通过参与胆道术后伴发多药耐药铜绿假单胞菌(PAE)胆道感染患者的药物治疗实践,探讨临床药师参与抗感染治疗,尤其是多药耐药菌的防治和开展药学监护的方法。方法临床药师参与临床治疗团队,根据患者血常规、血生化、体温以及腹痛等病情变化,提供合理性意见,与临床医师共同制定个体化治疗方案,并对其主要药物治疗进行药学监护。结果患者行经内镜逆行胰胆管造影(ERCP)术后第2天,血常规白细胞15.76×109/L,中性粒细胞80.9%,诉有发热、头疼等不适,体温38.7℃,考虑胆道感染尚未控制;针对患者感染部位、抗菌药物药动学及抗菌谱等特点、可能为耐药菌等情况,临床药师建议将抗菌药物头孢米诺调整为头孢哌酮/舒巴坦2 g,1次/12 h,静脉滴注,同时留取胆汁行细菌培养加药敏,待药敏结果报告后再作调整;考虑头孢哌酮/舒巴坦可干扰体内维生素K的代谢,造成出血倾向,建议加用维生素K1,医师采纳了临床药师建议,治疗3 d后患者体温逐渐得到控制,腹痛、头疼等不适症状有所缓解,复查血常规白细胞10.85×109/L,中性粒细胞75.2%;胆汁细菌培养3 d后回示多药耐药铜绿假单胞菌生长,药敏结果提示,对头孢哌酮/舒巴坦敏感,维持前抗感染治疗方案,治疗7 d后,患者痊愈出院。结论临床药师深入临床直接面向患者提供药学服务,参与制定抗感染个体化治疗方案,开展药学监护,对多药耐药菌的预防与治疗可发挥重要作用。

OBJECTIVE To seek the methods of providing individualized medications and pharmaceutical care for infected inpatients when clinical pharmacists worked in clinical departments,through participating drug therapy practice for multidrug-resistant Pseudomonas aeruginosa infections after biliary tract surgery.METHODS Clinical pharmacists participated in the drug therapy for an postoperative biliary inpatient with PAE infections;reasonable opinions were provided for individualized medications and special pharmaceutical cares were offered for monitoring the main drug therapy according to the results of blood routine,serum biochemical,body temperature and clinical manifestations of patients.RESULTS During joining in the drug therapy of the postoperative biliary inpatient,clinical pharmacists recommended the doctor to adjust cefminox for cefoperazone/sulbactam in time before the results of bacterial culture and drug susceptibility came out.Later the bacterial culture results suggested that there was PAE growing in bile and the bacteria was susceptible to cefoperazone/sulbactam.The patient recovered and discharged from hospital after the anti-infection treatment for 7 days.CONCLUSION Clinical pharmacists provide pharmaceutical care for patients directly in clinic,such as participating in setting individualized treatment for infections,which can provide effective drug therapy for multidrug-resistant organism infections and improve the quality of medication.