临床药师参与1例老年血液透析患者并发细菌及病毒感染的药物治疗实践

Analysis of Clinical Pharmacists Participating in Drug Treatment for an Aged Hemodialysis Patient with Bacterial and Virus Infections

目的:探讨临床药师参与血液透析感染患者治疗过程中用药监护的切入点和监护策略。方法:临床药师通过1例老年血液透析患者并发细菌及病毒感染的药物治疗实践过程,参与并优化患者治疗方案,以血液透析前后药品不良反应、药动学、药效学变化及抗病毒方案的分析为切入点。结果与结论:药师建议先后采用:哌拉西林/他唑巴坦2.25g、q8h(透析后补充0.75g),美罗培南0.5g、q12h(透析后补充0.5g),伏立康唑0.1g、bid和莫西沙星片0.4g、qd(透析后无需补充)的给药方式治疗,治疗期间应及时追踪患者肌酐清除率变化情况并及时调整用药剂量;拉米夫定片100mg/d抗乙肝病毒,并对患者提出合理的药学监护要点。医师采纳了该建议,患者获得满意疗效后出院。临床药师的参与可提高治疗效果,减少或避免药品不良反应。

OBJECTIVE：To investigate the breakthrough point of pharmaceutical care and strategies of clinical pharmacists participating in drug treatment for hemodialysis patients.METHODS：Clinical pharmacists participated in drug treatment for an aged hemodialysis patient with bacterial and virus infections and optimized therapeutic regimen using ADR,pharmacokinetics,pharmacodynamics and antivirus scheme as breakthrough point.RESULTS＆CONCLUSIONS：Clinical pharmacists provided suggestions,i.e.piperacillin/tazobactam 2.25 g,q8h （increased by 0.75 g after hemodialysis）;meropenem 0.5 g,q12h （increased by 0.5 g after hemodialysis）;voriconazole 0.1 g,bid and Moxifloxacin tablet 0.4 g,qd （supplement-free after hemodialysis）,monitoring changes of CrCl and adjusting drug dosage timely;Lamivudine tablet 100 mg/d against HBV,putting forward reasonable pharmaceutical care points.The suggestions were accepted by physicians,and then the patient discharged from hospital after cured.The participation of clinical pharmacist can improve therapeutic efficacy,and redace or avoid ADR.