心脏瓣膜择期手术患者并发医院获得性感染的抗感染治疗的药学监护分析

Analysis of Pharmaceutical Care of Anti-Infective Treatment in Patients Undergoing Elective Heart Valve Surgery Complicated By Hospital-Acquired Infection

目的:基于细菌耐药状况分析心脏瓣膜择期手术患者并发医院获得性感染的抗感染治疗的药学监护过程,为临床类似患者的抗感染治疗提供参考。方法与结果:患者因“活动后胸闷10年,近3个月胸闷加重”入院,其心脏彩超示二尖瓣重度狭窄合并轻度返流+三尖瓣重度返流,遂诊断为心脏瓣膜病,考虑择期手术;在入院的第2天和第15天,患者都出现了发热和感染指标异常的情况,且血培养都检出了大肠埃希菌,临床药师根据其药敏结果先后建议使用了哌拉西林-他唑巴坦钠和美罗培南,之后患者好转;入院第43天(心脏瓣膜手术后),患者感染指标再次明显异常,且发生感染性休克,遂经验性予美罗培南;之后行痰培养,检出产酸克雷伯菌,药敏试验显示其对美罗培南耐药,且耐药基因检测显示肺炎克雷伯菌碳青霉烯酶阳性,故临床药师建议使用头孢他啶-阿维巴坦钠治疗;10 d后,患者感染指征消失,痰培养连续2次回报阴性。结果:临床药师在对感染患者开展抗感染治疗药学监护的过程中,既要积极明确感染的病原菌,还应尽量掌握其耐药特点,以确保患者得到有效的抗感染治疗。

Objective:To analyze the pharmaceutical care process of anti-infective treatment in patients undergoing elective heart valve surgery complicated by hospital-acquired infection based on the bacterial resistance status and provide reference for anti-infective treatment in clinically similar patients.Methods and Results:The patient was admitted to the hospital due to "chest tightness after activity for 10 years and worsening in the past three months".The color Doppler ultrasonography of heart showed severe mitral stenosis combined with mild regurgitation and severe tricuspid regurgitation,so the patient was diagnosed with valvular heart disease and elective surgery was considered.On the 2nd and 15th days of admission,the patient experienced fever with abnormal infection indicators,and blood culture showed that Escherichia coli was detected.Based on the drug susceptibility test results,the clinical pharmacist recommended the use of piperacillintazobactam sodium and meropenem successively,and the patient improved.On the 43rd day of admission(after heart valve surgery),the patient's infection indicators became obviously abnormal again and septic shock occurred,so meropenem was empirically administered;later,the sputum culture was performed and klebsiella oxytoca was detected.The drug susceptibility test showed resistance to meropenem,and the test for drug resistance gene showed that Klebsiella pneumonia carbapenemase was positive,so the clinical pharmacist recommended the use of ceftazidime-avibactam sodium;10 days later,the patient's indications of infection disappeared and the results of two consecutive sputum cultures were negative.Conclusion:Clinical pharmacists shall actively identify the pathogenic bacteria of infection and try to understand their drug resistance characteristics when carrying out pharmaceutical care of anti-infective treatment for infected patients,to ensure that patients receive effective anti-infective treatment.