临床药师对1例肝移植术后并发多系统耐药菌感染患者的药学监护

Clinical Pharmacist Participated in the Pharmaceutical Care of a Patient with Multisystem Drug-resistant Bacteria Infection after Liver Transplantation

通过参与1例肝移植术后先后出现耐碳青霉烯鲍曼不动杆菌致肺部感染和多耐药铜绿假单胞菌致血流感染患者的治疗过程,临床药师在权衡治疗矛盾基础上,结合相关指南和文献,在药物选择、用药疗程、剂量调整等方面针对性地给出调整抗菌药物治疗方案等用药建议,通过医嘱重整判定影响他克莫司血药浓度波动的药物因素或基因多态性因素,为优化方案提供依据。临床医生多次采纳了临床药师的建议,患者感染得到有效控制,他克莫司血药浓度达治疗窗,未出现急性排斥反应。临床药师可在耐多药菌抗感染治疗、基于血药浓度监测的治疗方案调整、特殊人群用药方案调整等方面起到重要作用,为患者临床用药安全提供保障。

By participated in a patient with lung infection caused by carbapenem-resistant Acinetobacter baumannii and bloodstream infection caused by multi-drug resistant Pseudomonas aeruginosa after liver transplantation, clinical pharmacists from different approaches, on the basis of weighing treatment contradictions, combined with relevant guidelines and literature to give targeted adjustments of antimicrobial treatment plans and other personalized medication recommendations in terms of drug selection, duration, dosage adjustment, etc. And through the reorganization of doctor’s orders to determine the drug factors or genetic polymorphism factors that affect the blood concentration of tacrolimus, to provide a basis for the optimization plan. Clinicians have adopted the recommendations of clinical pharmacists. The patient’s infection has been effectively controlled. The blood concentration of tacrolimus has reached the therapeutic window and no acute rejection has occurred. Clinical pharmacists played a important role in the anti-infection treatment of multidrug-resistant bacteria, the adjustment of treatment plans based on drug concentration monitoring, and the adjustment of medication plans for special populations, which can provide guarantees for the safety of clinical medications for patients.