肺移植术后耐碳青霉烯类肺炎克雷伯菌肺炎患者抗感染治疗分析

Anti-infective Treatment of the Carbapenem-resistant Klebsiella Pneumoniae Pneumonia after Lung Transplantation:A Case Report

目的对1例肺移植术后患者并发耐碳青霉烯类肺炎克雷伯菌(CRKP)肺炎的抗感染治疗进行病例分析,探讨CRKP抗感染治疗药物选择,以期为临床CRKP抗感染治疗提供参考。方法临床药师全程参与肺移植术后患者的抗感染治疗,分析用于治疗CRKP感染常用药物碳青霉烯类、替加环素、多黏菌素B以及头孢他啶阿维巴坦的特点,从药物选择、给药剂量、给药方法的优化等方面进行药学服务,帮助临床医生制定合适的抗感染方案。结果治疗CRKP感染时,一般采用2或3种药物联合治疗。当MIC≤8 mg·L^(-1)时,碳青霉烯类药物可考虑为联合用药;若MIC>8 mg·L^(-1)时,则不建议选择碳青霉烯类药物(多黏菌素联用时则MIC可提高到16~32 mg·L^(-1))。替加环素用于治疗肺炎时,为提高其在肺内的浓度,可给予首剂负荷剂量为200 mg,维持剂量为100 mg,q12h的给药方案。为使多黏菌素B尽快达到有效稳态血药浓度,建议多黏菌素首剂给予2.0~2.5 mg·kg^(-1)的负荷剂量,维持剂量每12 h给予1.25~1.5 mg·kg^(-1)。头孢他啶阿维巴坦为治疗CRKP感染新的有效治疗药物,推荐剂量为2.5 g,q8h。通过对治疗方案的优化,患者感染得到有效控制,临床症状好转,病原学结果转阴,且未复发。结论临床药师充分发挥自己的专业特长,结合患者的病情,与医生共同制定抗感染治疗方案,有利于保障患者安全、合理、有效用药,体现临床药师的价值。

Objective To analyzed a case of carbapenem-resistant Klebsiella pneumoniae(CRKP)pneumonia after lung transplantation and discussed the choice of anti-infective drugs for CRKP,in order to provide a reference for clinical anti-infective treatment of CRKP.Methods Clinical pharmacists participated in the course of anti-infective treatment of patients after lung transplantation.The characteristics of carbapenems,tigecycline,polymyxin B,and ceftazidime-avibactam which were commonly used in the treatment of CRKP infection were analyzed.Pharmaceutical services were provided in terms of drug selection,dosage and treatment optimization in order to help clinicians formulate optimal anti-infective regimen.Results In the treatment of CRKP infection,two or three drugs are commonly used in combination.Carbapenems can be considered as a combination drug when MIC is equal or less than 8 mg·L^(-1).Carbapenems are not recommended when MIC is more than 8 mg·L^(-1)(MIC can be increased to 16-32 mg·L^(-1)when polymyxin is combined).When tigecycline is used in the treatment of pneumonia,in order to increase its concentration in lungs,200 mg of the loading dose and 100 mg q12h of the maintenance dose can be given.In order to make polymyxin B reach an effective steady-state plasma concentration as soon as possible,the loading dose of polymyxin B should be 2.0-2.5 mg·kg^(-1),and the maintenance dose should be 1.25-1.5 mg·kg^(-1)every 12 hours.Ceftazidime-avibactam is a new effective drug for the treatment of CRKP infection and the recommended dose is 2.5 g q8h.By optimizing the treatment plan,the infection was effectively controlled,and the clinical symptoms improved.The etiological results turned negative with no recurrence occurred.Conclusion Clinical pharmacists bring their specialty into a full play.Combined with the patient's condition,clinical pharmacists work out anti-infective treatment programs with doctors,which is conducive to ensure patients'safe,rational and effective use of drugs,and reflect the value of clinical pharmacists.