自身免疫性肝炎合并原发性胆汁性胆管炎继发耶氏肺孢子菌肺炎患者的药学监护

Pharmaceutical care of one case of pneumocystis yersoni pneumonia secondary to autoimmune hepatitis complicated with primary biliary cholangitis

自身免疫性肝炎(AIH)合并原发性胆汁性胆管炎(PBC)继发耶氏肺孢子菌肺炎1例女性患者,因“间断皮肤瘙痒8年,间断发热20 d”入院。患者3个月前被诊断为PBC合并AIH,经激素治疗后好转出院,院外持续规律口服激素治疗。此次入院诊断为呼吸窘迫综合征、重症肺炎、PBC、AIH。患者入院后经验性给予哌拉西林钠/他唑巴坦钠抗感染治疗,后经支气管肺泡灌洗液二代基因测序提示耶氏肺孢子菌感染。临床药师通过查阅相关文献建议给予甲氧苄啶-磺胺甲噁唑联合卡泊芬净治疗,同时监测患者用药疗效及可能出现的不良反应,根据患者的实际情况调整治疗方案,对患者进行用药、生活饮食等指导。经积极有效的治疗后患者的症状得到有效控制,好转出院。自身免疫性肝病是继发耶氏肺孢子菌肺炎的高危因素,致死率高。临床药师需通过综合研判患者的疾病状况、用药情况及检测结果,协同临床医师制定合理化、个体化的药物治疗方案,以提高药物治疗的安全性、有效性和经济性。此外,与医师建立良好的沟通,提高了患者对药师的信任,同时临床药师积极参与危重患者的药学管理有助于为患者安全有效的治疗提供保障,改善其临床预后。

A female patient who has been diagnosed as suffering from pneumocystis yersoni pneumonia secondary to primary biliary cholangitis(PBC)complicated with autoimmune hepatitis(AIH)was admitted due to intermittent skin pruritus for 8 years and fever for 20 days.She had been diagnosed with PBC and AIH more than 3 months ago and has received glucocorticoid therapy since then.After admission,the patient was diagnosed as suffering from respiratory distress syndrome,severe pneumonia,primary biliary cirrhosis and autoimmune hepatitis.Piperacillin sodium was given to her by doctors according to clinical experience,then the medicine was changed to trimethoprim-sulfamethoxazole and carpofungin based on the result of next-generation sequencing(NGS)of bronchoalveolar lavage fluid showing infection by pneumocystis jirovecii.Meanwhile,clinical pharmacists made individualized regimens by adjusting anti-infection drugs and carry out pharmaceutical monitoring on the therapeutic efficacy and adverse reactions.The patient was educated on medication,life and diet.Finally,she was discharged with a good prognosis.Autoimmune liver diseases are high risk factors for secondary pneumocystis yerbii pneumonia and has a high mortality.This paper summarized the important role of clinical pharmacists in comprehensively evaluating patients'disease status,drug use and test results,and cooperating with clinicians to develop rational and individualized drug treatment plans to improve the safety,effectiveness and economy of drug treatment.Establishing good communication with doctors is helpful for improving patients'trust in pharmacists.Clinical pharmacists actively participate in the pharmaceutical management of critically ill patients can guarantee the safe and effective treatment of patients and significantly improve the clinical prognosis.