1例卒中相关肺炎患者的药学监护

Pharmaceutical care on a patient with stroke associated pneumonia

1例77岁男性患者,因新发脑梗后肺部感染入院,入院时合并有高血压、酒精性肝硬化、脑出血后遗症、慢性阻塞性肺病等多种疾病,给予抗感染、清热解毒、祛痰、活血化瘀、营养脑细胞及对症治疗。针对患者卒中相关肺炎的情况,临床药师根据其疾病特点协助医生经验性选择美罗培南,覆盖卒中相关肺炎常见的致病菌,根据痰培养结果,结合病原菌的特点、药物的抗菌谱进行抗菌药的调整,针对支原体选择莫西沙星,针对克柔念珠菌选择伏立康唑;考虑患者新发脑梗及酒精性肝硬化,对莫西沙星神经系统不良反应及伏立康唑引起肝功能损害的不良反应进行监测;对莫西沙星与多索茶碱相互作用进行密切监测,并利用药动学知识对伏立康唑治疗方案进行优化。

One 77-year-old male patient was hospitalized because of lung infection after new cerebral infarction. And this patient had the history of high blood pressure, alcoholic cirrhosis, cerebral hemorrhage sequela, chronic obstructive pulmonary disease and other diseases. He was given the therapy of anti-infection, clearing away heat and toxic materials, expectorant, promoting blood circulation to remove blood stasis, nutrition of brain cells, and symptomatic treatment. According to the characteristics of stroke associated pneumonia of this patient, clinical pharmacists assisted doctors to choose meropenem for empiric antibiotic therapy, which can cover the common pathogens of stroke-related pneumonia. Moxifloxacin was selected for controlling mycoplasma, voriconazole was selected for treatment of candida krusei according to the results of sputum culture, the characteristics of pathogens and antimicrobial spectrum. Considering the new cerebral infarction and alcoholic cirrhosis of the patient, the nervous system adverse reactions caused by moxifloxacin and hepatic dysfunction impaired by voriconazole were monitored. Clinical pharmacists also closely monitored the interaction between moxifloxacin and doxofylline, and optimized voriconazole therapeutic schedule based on pharmacokinetic knowledge.