1例糖尿病酮症酸中毒患者伴发肺毛霉病的抗感染治疗实践体会

Practical Experience of Anti-infection Treatment in a Patient with Diabetic Ketoacidosis Accompanied by Pulmonary Mucormycosis

目的:分析1例糖尿病酮症酸中毒患者伴发毛霉病的临床诊疗过程,为临床此类复杂感染患者的诊断和治疗提供参考。方法与结果:患者因“咳嗽、咳痰1周”而收治入院,但次日因血糖报告危急值,考虑为糖尿病酮症酸中毒,遂转至上级医院治疗;患者胸部CT提示肺部感染,遂经验性予多西环素+头孢哌酮-舒巴坦钠+阿米卡星;但抗感染治疗十余日后,感染控制仍不佳,遂请专家会诊,专家考虑患者真菌感染可能性较大,于是加用注射用两性霉素B治疗,之后支气管黏膜组织果然检查出真菌团块(倾向于毛霉);之后,抗感染治疗方案又调整为注射用两性霉素B胆固醇硫酸酯复合物+泊沙康唑混悬口服液+头孢哌酮-舒巴坦钠;但抗感染治疗1个多月后,感染仍未完全控制,遂请临床药师会诊,临床药师综合患者病情、既往用药和相关诊疗指南,建议将抗感染治疗方案调整为注射用艾沙康唑+美罗培南,医生采纳了建议;之后,患者咳嗽、咳痰、发热等感染症状明显改善,而胸部CT亦提示肺部病灶明显吸收。结论:对于复杂难治的感染性疾病,临床应充分考虑真菌感染的可能,并积极探寻病原体;而在针对性治疗时,还应优选药物的品种和剂型,并实时观察其疗效,以确保患者得到及时有效的治疗。

Objective:To analyze the clinical diagnosis and treatment process of a patient with diabetic ketoacidosis accompanied by mucormycosis,and to provide reference for the diagnosis and treatment of patients with such complicated infection.Methods and Results:The patient was admitted to the hospital due to''cough and expectoration for 1 week''.However,the next day,due to the critical value in the blood glucose report,the patient was considered diabetic ketoacidosis,and was transferred to a higher hospital for treatment.The patient's chest CT showed pulmonary infection,so doxycycline+cefoperazone sulbactam sodium+amikacin was given empirically.However,after more than ten days of anti-infection treatment,the infection was still controlled poorly,so experts were invited for consultation.Experts considered a high possibility of fungal infection in the patient,so amphotericin B for injection was added,and then fungal clumps(preferring mucor)were found in the bronchial mucosa tissue.Later,the anti-infection treatment regimen was adjusted to amphotericin B cholesterol sulfate complex for injection+posaconazole suspension oral liquid+cefoperazone sulbactam sodium.However,after more than one month of anti-infection treatment,the infection was still not completely controlled,so the clinical pharmacist was invited for consultation,who suggested adjusting the anti-infection treatment regimen to isavuconazole for injection+meropenem based on the patient's condition,previous medication and relevant diagnosis and treatment guidelines,and the doctor adopted the suggestion.After that,the cough,expectoration,fever and other infectious symptoms of the patient were significantly relieved,and chest CT also showed that the lung lesions were obviously absorbed.Conclusion:For complicated and refractory infectious diseases,the possibility of fungal infection should be fully considered in clinical practice,and the pathogen should be actively explored.In targeted treatment,the varieties and dosage forms of drugs should also be optimized,and their efficacy should be observed in real time to ensure timely and effective treatment on patients.