对1例肾功能延迟恢复的老年患者合理使用万古霉素的药学监护

Rational use of vancomycin in elderly patient with delayed renal function recovery

1例82岁女性患者,因"呼吸困难,咳嗽咳痰,胸痛1个月余,加重3d"收入心脏科,既往有慢性喘息型支气管炎、阻塞性肺气肿、高血压,入院后诊断为慢性阻塞性肺疾病急性加重合并肺部感染和急性冠脉综合征,给予头孢米诺钠联合依替米星抗感染治疗效果不佳后,痰培养为黄曲霉,给予万古霉素联合头孢哌酮舒巴坦及伏立康唑注射液,血肌酐逐渐升高,临床药师评估其治疗方案,并持续关注其药物治疗,对患者进行全程药学监护,在发生万古霉素致肾功能不全、停用万古霉素后血肌酐继续升高时进行了及时的用药分析,与医生充分沟通并提出导致患者肾功能恢复延迟的原因及用药建议,在停用万古霉素第9天后患者血肌酐逐渐下降;停用万古霉素15 d后及24 d后万古霉素的血药浓度分别为11.44μg·mL^(-1)和3.55μg·mL^(-1),计算其T_(1/2)分别为284 h和131 h。

One 82-year-old female patient with the history of chronic asthmatic bronchitis, obstructive emphysema, hypertension was admitted to hospital after three days of symptom exacerbation due to expiratory dyspnea, coughing and expectoration, chest pain for more than one month. The patient was diagnosed as acute exacerbation of chronic obstructive pulmonary disease with pulmonary infection and acute coronary syndrome. The effect was not good after the patient was given cefminox sodium and etimicin for anti-infective treatment. The sputum culture was Aspergillus flavus. Then vancomycin combined with cefoperazone sulbactam and voriconazole injection were used, while serum creatinine gradually increased. The therapeutic regimen was evaluated, and the pharmaceutical care was carried out by clinical pharmacist. Timely medication analysis and suggestions were performed when vancomycin-induced renal insufficiency occurred and blood creatinine continued rising after discontinuation of vancomycin. Clinical pharmacist fully communicated with the doctors, analyzed the causes of delayed renal function recovery and provided medication recommendations. Nine days after discontinuation of vancomycin, the serum creatinine decreased gradually. 15 days and 24 days after the discontinuation of vancomycin, the plasma concentrations of vancomycin were 11.44 μg·mL^-1 and 3.55 μg·mL^-1, respectively. The results of T1/2 were calculated to be 284 h and 131 h, respectively.