肾脏替代治疗脓毒症患者美罗培南剂量选择的临床研究

A clinical study on the dose selection of meropenem for sepsis patients with renal replacement treatment

目的 对进行连续性肾脏替代治疗（CRRT）的脓毒症患者使用不同剂量的美罗培南，研究分析不同剂量的疗效及不良反应。方法 选取2014-05～2017-05在我院治疗的72例脓毒症患者进行回顾性分析，所有患者均需行CRRT及美罗培南抗感染治疗。按照随机数字法将所有患者分为A组24例（将0.5 g/12 h的美罗培南＋100 mL浓度为0.9% NaCl注射液混合稀释后，给予静脉滴注）；B组24例（将1 g/12 h的美罗培南＋100 mL浓度为0.9% NaCl注射液混合稀释后，给予静脉滴注）；C组24例（将2 g/12 h的美罗培南＋100 mL浓度为0.9% NaCl注射液混合稀释后，给予静脉滴注）；观察三组患者治疗前及治疗后7 d的血药浓度、 APACHEⅡ评分及血清降钙素原（PCT）变化，记录三组菌株鉴定结果、治疗后细菌清除率及用药后发生的不良反应。结果 A组%T〉MIC为51.43±2.87，B组为80.13±7.14，C组为86.57±4.66，C组的%T〉MIC最高，组间比较差异均有统计学意义（F=311.37,P〈0.01）；而A、B、C组患者的PCT分别为（1.68±1.22）ng/L、（1.54±1.27）ng/L和（1.31±1.08）ng/L，组间比较差异无统计学意义（F=0.589，P=0.558）；A、B、C组患者的APACHEⅡ评分分别为（13.72±4.55）分、（13.11±4.35）分和（11.01±4.62）分，组间比较差异无统计学意义（F=2.387，P=0.099）；A组检出G-菌8例（33.33%）、B组检出6例（25.00%）、C组检出4例（16.67%）；A、B、C组细菌清除率分别为62.50%、70.83%、87.50%，组间比较差异有统计学意义（P〈0.05）。本次研究中未发生更多的不良反应。结论 美罗培南剂量增加能够增加%T〉MIC值，CRRT治疗脓毒症患者中使用美罗培南能够有效清除细菌，且大剂量的美罗培南清除效果更佳，具有临床参考意义。

Objective The sepsis patients are given different doses of meropenem during continuous renal replacement therapy （CRRT）, therefore we aimed to investigate the curative effect and adverse reaction of different doses of meropenem.Methods From May 2014～May 2017, we retrospectively analyzed 72 patients with sepsis in our hospital. All the patients were given meropenem for anti-infection treatment and CRRT. All the patients were randomly divided into A group of 24 cases ［Meropenem （0.5 g/12 h） and 100 mL sodium （0.9%） chloride injection were diluted to give intravenous drip］; 24 cases in group B ［Meropenem （1g/12h） and 100 mL sodium （0.9%） chloride injection were diluted to give intravenous drip］; 24 cases in group C ［Meropenem （2g/12h） and 100 mL sodium （0.9%） chloride injection were diluted to give intravenous drip］; plasma concentration before and after treatment, the APACHE Ⅱ score and serum procalcitonin （PCT） changes after treatment, identification of the bacterial strains, bacterial clearance after treatment and adverse reaction after medication were respectively detected or recorded.Results %T〉MIC in group A was 51.43±2.87, in group B was 80.13±7.14, in group C was 86.57±4.66, %T〉MIC in group C was the highest, the difference among the groups was significant （F=311.37,P〈0.01）. PCT in group A, B and C were（1.68±1.22） ng/L,（1.54±1.27） ng/L and （1.31±1.08） ng/L, respectively, and there were no significant differences among the groups（F=0.589,P=0.558）. APACHE Ⅱ score in group A, B and C were （13.72±4.55）,（13.11±4.35） and （11.01±4.62）, respectively; there was no significant difference between the groups （F=2.387,P=0.099）. In group A, G-bacteria were detected in 8 cases （33.33%）, group B was detected in 6 cases （25.00%）, and group C was detected in 4 cases （16.67%）. Bacterial clearance rates of group A, B and C were 62.50%, 70.83% and 87.50%, respectively; there was statistical significant differences among the groups （P〈0.05）.Conclusion Meropenem dose increase can increase the value of %T〉MIC, CRRT in patients with sepsis in the use of meropenem can effectively remove bacteria. The present study provides clinical reference for meropenem using in sepsis patients that high dose shows better bacteria scavenging effect than low dose.