临床药师参与1例GFAP星形细胞病合并多重耐药菌肺部感染患者的药学监护

Clinical Pharmacist Participated in Pharmaceutical Care for A Patient with GFAP Astrocytopathy Complicated by Multi-drug Resistant Bacterial Pulmonary Infection

关键词:  GFAP星形细胞病  多重耐药菌肺部感染  多粘菌素B致皮肤色素沉着  临床药师  药学监护

Key words:  GFAP astrocytopathy  multidrug-resistant pulmonary infection  polymyxin B causes skin pigmentation  clinical pharmacist  pharmaceutical care

摘要:

目的 探讨临床药师在GFAP星形细胞病合并多重耐药菌肺部感染患者治疗过程中的作用。方法 临床药师参与1例GFAP星形细胞病合并多重耐药菌肺部感染患者的诊疗过程。临床药师对患者使用激素冲击治疗过程中出现急性上消化道出血进行了监护,建议停用甲泼尼龙,使用泮托拉唑钠40mg,bid,静脉泵入抑酸等止血冶疗；针对患者肺部感染症状与体征、病原学结果及所用抗菌药物的药代动力学特性,建议将亚胺培南西司他丁更改为硫酸多粘菌素B(首剂100万单位,维持50万单位),q12h联合替加环素(首剂200mg,维持100mg),q12h,针对后续感染控制不佳,建议停用多粘菌素B与替加环素,更改为磷霉素钠4g,q8h联合美罗培南2g,q8h输注 3小时；并对患者使用多粘菌素B过程中出现皮肤色素沉着的不良反应进行了鉴别分析。结果 临床医师采纳了临床药师的建议。经治疗,患者好转,准予出院。结论 临床药师通过参与GFAP星形细胞病合并多重耐药菌肺部感染患者的药学监护,协助医师优化了治疗方案,保证了患者用药的有效性和安全性。

Abstract:

OBJECTIVE To explore the role of clinical pharmacists in the treatment process of patients with GFAP astrocytopathy complicated by multidrug-resistant pulmonary infection. METHODS Clinical pharmacist participated in the diagnosis and treatment process of a patient with GFAP astrocytopathy and multidrug-resistant pulmonary infection. The pharmacist monitored the patient who experienced acute upper gastrointestinal bleeding during steroid therapy, suggested discontinuing methylprednisolone, and recommended pantoprazole sodium 40mg, bid, intravenously infused for hemostasis treatment. Based on the patient's pulmonary infection symptoms and signs, etiological results, and the pharmacokinetic characteristics of the antibiotics used, it was suggested to change imipenem-cilastatin to polymyxin B sulfate(initial dose 1 million units, maintenance 500,000 units), q12h combined with tigecycline(initial dose 200mg, maintenance 100mg), q12h. Due to poor infection control, it was suggested to discontinue polymyxin B and tigecycline, and change to fosfomycin sodium 4g, q8h combined with meropenem 2g, q8h infused over 3 hours. The adverse reactions of patients with skin pigmentation during the use of polymyxin B were identified and analyzed. RESULTS The clinical physician accepted the recommendations of the clinical pharmacist. After treatment, the patient improved and was discharged. CONCLUSION The clinical pharmacist, through participation in the pharmaceutical care of a patient with GFAP astrocytopathy and multidrug-resistant pulmonary infection, assisted the physician in optimizing the treatment plan, ensuring the efficacy and safety of the patient's medication use.