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鹦鹉热衣原体是在革兰染色阴性需氧细胞内寄生的病原体,主要宿主为鸟类,吸入鹦鹉热衣原体污染的气溶胶可致病,人际间传播较为罕见,主要通过接触鸟类的排泄物感染,肺是主要受累器官之一,严重者可致呼吸衰竭[1]。重症肺炎又是一种起病急、进展迅速、病死率高、治疗困难且预后较差的呼吸系统疾病,是严重威胁人类生命健康的感染性疾病之一[2]。临床药师发挥药学专业优势,协助医师优化治疗方案,实施药学监护,提高合理用药和临床疗效。本文就临床药师参与1例鹦鹉热衣原体感染致重症肺炎并发药物性肝损伤老年患者的药学实践报道如下。
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患者入科后完善相关检查(血常规、肝肾功能、电解质、血气、CRP)等,抗感染治疗前留取血培养、痰培养、尿培养行病原学检查。初始经验性予替考拉宁0.2 g qd ivgtt联合亚胺培南-西司他丁钠0.5 g q8h ivgtt抗菌治疗,同时予抗凝、营养支持、补液等对症支持治疗。12月14日(D3),体温较前升高,最高39.1℃,血常规:白细胞(WBC)12.7×109/L,中性粒细胞百分比(N%)95.9%,CRP 98.79 mg/L。呼吸机有创通气,气管镜检查:咽喉部较多黄色痰痂形成,黏膜充血,水肿较明显,尤以右侧气管主支气管及各级支气管炎性改变。患者感染加重,医师和药师共同讨论后,方案调整为亚胺培南-西司他丁钠0.5 g q6h ivgtt联合利奈唑胺0.6 g q12h ivgtt。12月16日(D5),Tmax 39℃,血常规:WBC 11.2×109/L,N% 96.9%,CRP 96.55 mg/L。双肺呼吸音粗,湿啰音较前加重,胸部X线:双肺炎症较前进展。气道分泌物基因二代测序结果回报:鹦鹉热衣原体序列数38。气道吸出物普通培养:白念珠菌。抗感染方案调整为阿奇霉素0.5 g qd ivgtt、多西环素0.1 g q12h 胃管注入(首剂加倍)、氟康唑氯化钠0.4 g qd ivgtt。12月21日(D10),Tmax 37.4℃,化验报告:WBC 10.8×109/L,N% 93.4%,CRP 46.41 mg/L,总胆红素(TBIL)18.4 U/L,丙氨酸氨基转移酶(ALT)115 U/L,天门冬氨酸氨基转移酶(AST)311 U/L。气管吸出物有少量白念珠菌,1,3-β-D葡聚糖检测结果正常,胸部X线:右肺炎症,较前有所吸收。评价治疗有效。但患者肝酶水平持续升高,分析可能药物性肝损伤(DILI),加用多烯磷脂酰胆碱232.5 mg qd ivgtt联合异甘草酸镁200 mg qd ivgtt保肝治疗。12月22日(D11),Tmax 37℃,化验报告:WBC 5×109/L,N% 70.9%,CRP 67 mg/L,ALT 124 U/L,AST 342 U/L,仍维持原方案治疗。12月23日(D12),Tmax 37.7℃,气道吸出物未培养出白念株菌,ALT 204 U/L,AST 641 U/L,ALP 82 U/L,INR 1.79。患者肝酶急剧升高,抗感染方案调整为多西环素0.1 g q12h联合克拉霉素0.5 g q12h,密切监测患者肝功能。1月2日(D22),感染基本控制。出院后继续予多西环素片治疗同时水飞蓟宾葡甲胺片保肝,1周后经回访,预后良好。
其住院期间WBC、CRP指标变化见图1,肝功能变化见图2,主要治疗药物见表1。
表 1 住院期间主要治疗药物
药物 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 D16 D17 D18 D19 D20 D21 D22 亚胺培南-西司他丁钠 0.5 g q8h 0.5 g q6h 替考拉宁 0.2 g qd 利奈唑胺 0.6 g q12h 氟康唑氯化钠 400 mg qd 阿奇霉素 0.5 g qd 多西环素片 0.1 g q12h 克拉霉素片 0.5 g q12h 多烯磷脂酰胆碱 232.5 mg qd 异甘草酸镁 200 mg qd
Treatment and pharmaceutical care of one patient with Chlamydia psittaci pneumonia complicated by drug-induced liver injury
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摘要:
目的 通过参与鹦鹉热衣原体感染致重症肺炎并发药物性肝损伤老年患者的药学监护,探讨临床药师在合理用药中的作用。 方法 临床药师参与1例鹦鹉热衣原体重症肺炎并发药物性肝损伤患者的治疗,根据基因二代测序结果,通过查阅资料了解病原菌特点,结合患者肝肾功能及临床治疗效果与医师共同制订和调整用药方案,在分析疾病、调整用药、不良反应等方面实施个体化药学监护,并进行患者教育。 结果 初始经验性给予替考拉宁联合亚胺培南-西司他丁钠抗感染治疗效果不佳,确诊鹦鹉热衣原体及白念珠菌感染后,予多西环素联合阿奇霉素及氟康唑抗感染治疗,药学监护中发现药物性肝损伤的不良反应,临床药师协助医师调整方案为多西环素联合克拉霉素,并进行异甘草酸镁联合多烯磷脂酰胆碱保肝对症处理后,患者感染和肝功能明显好转,预后良好。 结论 临床药师运用专业知识为患者提供个体化的药学服务,有助于提高临床用药的合理性、安全性及有效性。 Abstract:Objective To explore the role of clinical pharmacists in rational drug use through the pharmacy care of an elderly pneumonia patient with Chlamydia psittaci infection and drug-induced liver injury. Methods The clinical pharmacists participated in the treatment of one patient with Chlamydia psittaci pneumonia and drug-induced liver injury. Based on the results of second-generation gene sequencing, the characteristics of the pathogen were learned by literature search. The clinical pharmacists monitored the patient’s liver and kidney function, provided a new medication treatment plan to Doctors, and performed patient education during the treatment. Results The initial empirical anti-infective treatment with teicoplanin and imipenem-cilastatin was not effective. After the diagnosis of Chlamydia psittaci and Candida albicans infection, the combination of doxycycline with azithromycin and fluconazole was administered. Drug-induced liver injury was found with this treatment. The clinical pharmacist proposed to switch to doxycycline and clarithromycin with co-administration of magnesium isoglycyrrhizinate and polyene phosphatidylcholine to protect the liver. With this new regime, patient's liver function was improved and the infection was under control. Conclusion Individualized pharmaceutical cares provided by clinical pharmacists helped the safe, rational and effective use of medications. -
表 1 住院期间主要治疗药物
药物 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 D16 D17 D18 D19 D20 D21 D22 亚胺培南-西司他丁钠 0.5 g q8h 0.5 g q6h 替考拉宁 0.2 g qd 利奈唑胺 0.6 g q12h 氟康唑氯化钠 400 mg qd 阿奇霉素 0.5 g qd 多西环素片 0.1 g q12h 克拉霉素片 0.5 g q12h 多烯磷脂酰胆碱 232.5 mg qd 异甘草酸镁 200 mg qd -
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