临床药师参与纹带棒状杆菌致肺部感染合并肾功能不全患者的药学实践

Pharmaceutical practice in a renal insufficiency patient with pulmonary infection caused by Corynebacterium striatum

1例88岁女性患者,因“咳嗽、咳痰4 d,胸痛1 d”入院,诊断为慢性肾功能不全、重症肺炎,给予气管插管辅助通气、头孢哌酮钠舒巴坦钠联合氟康唑抗感染治疗,后因支气管肺泡灌洗液细菌培养及基因测序结果均提示纹带棒状杆菌感染,故加用利奈唑胺葡萄糖注射液(0.6 g,q 12 h,ivgtt),使用利奈唑胺第6天测谷浓度为13.21 mg·L^(-1),PLT 55×10^(9)·L^(-1),判断为利奈唑胺血药浓度超出上限并引起骨髓抑制,临床药师建议停用利奈唑胺并换用万古霉素,临床医生采纳并给予注射用万古霉素(0.5 g,qod,ivgtt),期间监测万古霉素谷浓度为5.7 mg·L,临床药师分析万古霉素谷浓度不达标的原因,并建议给药方式由静脉滴注改为24 h持续输注,临床医生采纳意见,后复测万古霉素谷浓度为19.6 mg·L,19 d后患者感染得到控制,PLT恢复正常,病情稳定后患者转院治疗。

An 88-year-old female patient was admitted to hospital due to cough and expectoration for 4 days and chest pain for 1 day,and was diagnosed with chronic renal insufficiency,severe pneumonia.Assisted ventilation by trachea cannula,antiinfection therapy with cefoperazone sodium and sulbactam sodium and fluconazole were given to her.Results of bacterial culture and gene sequencing of bronchoalveolar lavage fluid(BALF)showed Corynebacterium striatum,so linezolid glucose injection(0.6 g,q 12 h,ivgtt)was added.6 days later,the trough concentration of linezolid was 13.21 mg·L^(-1) and the count of PLT was 55×10^(9)L^(-1),based on which marrow depression caused by high-dose of linezolid was considered.And then,linezolid was replaced by vancomycin(0.5 g,qod,ivgtt)under the suggestion of clinical pharmacists.The trough concentration of vancomycin was 5.7 mg·L^(-1) during the period of the treatment.Clinical pharmacists analyzed the possible reasons for the low trough concentration of vancomycin and suggested giving vancomycin through continuous infusion for 24 h.Clinicians adopted the advice.Then the trough concentration of vancomycin rose to 19.6 mg·L^(-1).19 days later,the infection was controlled and the count of PLT returned to normal.The patient was transferred to another hospital in stable condition.