1例卒中相关性肺炎老年患者抗感染治疗的实践体会

Practice Experience of Anti-infective Treatment in an Elderly Patient with Stroke-associated Pneumonia

目的:分析1例卒中相关性肺炎老年患者抗感染治疗的治疗过程,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“左侧肢体无力,意识不清,伴肢体抽搐4 d”收治入院,结合其头颅CT检查结果,初步诊断为卒中,而其胸部CT结果提示存在肺部感染,考虑为卒中相关性肺炎,遂经验性予头孢他啶治疗;4 d后,痰标本中检出肺炎克雷伯菌(超广谱β-内酰胺酶检查呈阴性);又6 d后,患者突发高热,且白细胞计数、中性粒细胞百分比、C反应蛋白等感染指标明显升高,遂将头孢他啶改为亚胺培南-西司他丁钠,但感染症状并未明显好转;又3 d后,痰标本中检出金黄色葡萄球菌(对甲氧西林耐药),遂建议加用万古霉素;又6 d后,感染仍未明显消退,遂将万古霉素调整为利奈唑胺,但感染仍不时反复;之后,痰标本中检出大肠埃希菌(超广谱β-内酰胺酶检查呈阳性),遂予哌拉西林-他唑巴坦钠;3 d后,患者感染基本消退,遂出院。结论:卒中相关性肺炎具有病原菌谱复杂、混合感染多久的特点,并且疾病过程中病原菌往往多变;对此,临床药师应积极探寻卒中相关性肺炎的病原菌,从而及时予以针对性抗感染治疗,以确保患者尽快康复。

Objective:To analyze the anti-infective treatment process of an elderly patient with stroke-associated pneumonia,and provide reference for the anti-infective treatment in clinically similar patients.Methods and Results:The patient was admitted to the hospital due to "weakness of left limb,unconsciousness,and limb twitching for 4 days".Based on the head CT scan results,the patient was initially diagnosed with stroke,and the chest CT scan results suggested the presence of pulmonary infection,which was considered to be stroke-associated pneumonia,then the patient was empirically treated with ceftazidime;4 days later,Klebsiella pneumoniae was detected in the sputum specimen(negative for the extended-spectrum β-lactamase test);6 days later,the patient had high fever suddenly,and the infection indicators such as WBC count,neutrophil percentage,C-reactive protein increased significantly,so ceftazidime was changed to imipenem-cilastatin sodium,but the infection symptoms did not improve significantly;3 days later,Staphylococcus aureus(resistant to methicillin) was detected in the sputum specimen,so it is recommended to add vancomycin;6 days later,the infection had not subsided obviously,so vancomycin was adjusted to linezolid,but the infection still recurred from time to time;subsequently,Escherichia coli was detected in the sputum specimen(positive for the extended-spectrumβ-lactamase test),so piperacillin-tazobactam sodium was administered;3 days later,the patient's infection basically subsided and he/she was discharged.Conclusion:Stroke-associated pneumonia is characterized by a complex spectrum of pathogenic bacteria and long-lasting mixed infections,and the pathogenic bacteria are often changeable in the disease process.Therefore,clinical pharmacists should actively explore the pathogenic bacteria of stroke-associated pneumonia,so as to provide targeted anti-infective treatment in a timely manner and ensure that patients recover as quickly as possible.