Message Board

Respected readers, authors and reviewers, you can add comments to this page on any questions about the contribution, review,        editing and publication of this journal. We will give you an answer as soon as possible. Thank you for your support!

Name
E-mail
Phone
Title
Content
Verification Code
Turn off MathJax
Article Contents

LUO Jingjing, WU Xinan, Xue Gang, Xie Zhengdong, Ye Jianbo, RONG Chengting. The pharmaceutical care by clinical pharmacists for a foot injury patient with postoperative MRSA infection[J]. Journal of Pharmaceutical Practice and Service. doi: 10.12206/j.issn.1006-0111.202102004
Citation: LUO Jingjing, WU Xinan, Xue Gang, Xie Zhengdong, Ye Jianbo, RONG Chengting. The pharmaceutical care by clinical pharmacists for a foot injury patient with postoperative MRSA infection[J]. Journal of Pharmaceutical Practice and Service. doi: 10.12206/j.issn.1006-0111.202102004

The pharmaceutical care by clinical pharmacists for a foot injury patient with postoperative MRSA infection

doi: 10.12206/j.issn.1006-0111.202102004
  • Received Date: 2021-02-04
  • Rev Recd Date: 2021-06-10
  • Available Online: 2022-01-12
  •   Objective  To explore the clinical pharmacist’s role in drug therapy and monitoring for the patient with postoperative MRSA infection.   Methods  Clinical pharmacists participated in planning anti-infective treatment, antimicrobial medication selection, identification of high-risk factors for MRSA infection, evaluation of vancomycin efficacy, dosage adjustment using TDM technology, monitoring and management of vancomycin adverse reactions.  Results  With the pharmaceutical care provided by clinical pharmacists, the patient received effective treatment with minimal vancomycin-related adverse reactions.   Conclusion  Clinical pharmacists played an important role in accelerating patient recovery by rational and safe medication use.
  • [1] BERRÍOS-TORRES S I, UMSCHEID C A, BRATZLER D W, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017[J]. JAMA Surg,2017,152(8):784-791. doi:  10.1001/jamasurg.2017.0904
    [2] 巴特利特, 奥威特, 等. ABX指南: 感染性疾病的诊断与治疗[M]. 北京: 科学技术文献出版社, 2012
    [3] 葛瑛. 《耐甲氧西林金黄色葡萄球菌感染防治专家共识》解读[J]. 中国临床医生, 2014, 42(3):11-12.
    [4] 万古霉素临床应用中国专家共识(2011版)[J]. 中国新药与临床杂志, 2011, 30(8): 561-573
    [5] BRATZLER D W, DELLINGER E P, OLSEN K M, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery[J]. Am J Health Syst Pharm,2013,70(3):195-283. doi:  10.2146/ajhp120568
    [6] RYBAK M J, LE J, LODISE T P, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: a revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists[J]. Am J Health Syst Pharm,2020,77(11):835-864. doi:  10.1093/ajhp/zxaa036
    [7] 何志超, 伍俊妍, 邱凯锋. 万古霉素个体化给药临床药师指引[J]. 今日药学, 2015, 25(2):78-82.
    [8] ÁLVAREZ R, LÓPEZ CORTÉS L E, MOLINA J, et al. Optimizing the clinical use of vancomycin[J]. Antimicrob Agents Chemother,2016,60(5):2601-2609. doi:  10.1128/AAC.03147-14
    [9] 唐莲, 严晓薇, 彭秋菊, 等. 肾功能亢进患者万古霉素血药浓度监测与临床疗效分析[J]. 中国医院药学杂志, 2018, 38(15):1629-1632.
    [10] 王凌, 眭玉霞. 渗透性治疗对神经危重症患者万古霉素血药浓度的影响[J]. 中国执业药师, 2016, 13(010):3-5.
    [11] HOBBS A L, SHEA K M, ROBERTS K M, et al. Implications of augmented renal clearance on drug dosing in critically ill patients: a focus on antibiotics[J]. Pharmacotherapy,2015,35(11):1063-1075. doi:  10.1002/phar.1653
    [12] HEALY D P, SAHAI J V, FULLER S H, et al. Vancomycin-induced histamine release and "red man syndrome": comparison of 1- and 2-hour infusions[J]. Antimicrob Agents Chemother,1990,34(4):550-554. doi:  10.1128/AAC.34.4.550
    [13] 广东省药学会. 临床药师术后疼痛管理指引[J]. 今日药学, 2019, 29(4):217-227.
    [14] European Association for the Study of the Liver. Clinical Practice Guidelines: Drug-induced liver injury. J Hepatol, 2019, 70(6): 1222-1261.
    [15] 周红玲, 刘年开, 丁楠. 万古霉素致严重肝损害1例[J]. 中国执业药师, 2012, 9(10):40-41.
    [16] 梁瑜, 孟真, 仓怀芹, 等. 注射用盐酸万古霉素致急性药物性肝损伤1例分析[J/OL]. 中国药物警戒, (2020-12-28) [2021-05-12]. http://kns.cnki.net/kcms/detail/11.5219.R.20201228.1229.002.html
    [17] SERRANTI D, MONTAGNANI C, INDOLFI G, et al. Antibiotic induced liver injury: what about children? J Chemother,2013,25(5):255-272. doi:  10.1179/1973947813Y.0000000090
    [18] CADLE R M, MANSOURI M D, DAROUICHE R O. Vancomycin-induced elevation of liver enzyme levels[J]. Ann Pharmacother,2006,40(6):1186-1189. doi:  10.1345/aph.1G668
  • 加载中
通讯作者: 陈斌, bchen63@163.com
  • 1. 

    沈阳化工大学材料科学与工程学院 沈阳 110142

  1. 本站搜索
  2. 百度学术搜索
  3. 万方数据库搜索
  4. CNKI搜索

Figures(1)

Article Metrics

Article views(2917) PDF downloads(52) Cited by()

Related
Proportional views

The pharmaceutical care by clinical pharmacists for a foot injury patient with postoperative MRSA infection

doi: 10.12206/j.issn.1006-0111.202102004

Abstract:   Objective  To explore the clinical pharmacist’s role in drug therapy and monitoring for the patient with postoperative MRSA infection.   Methods  Clinical pharmacists participated in planning anti-infective treatment, antimicrobial medication selection, identification of high-risk factors for MRSA infection, evaluation of vancomycin efficacy, dosage adjustment using TDM technology, monitoring and management of vancomycin adverse reactions.  Results  With the pharmaceutical care provided by clinical pharmacists, the patient received effective treatment with minimal vancomycin-related adverse reactions.   Conclusion  Clinical pharmacists played an important role in accelerating patient recovery by rational and safe medication use.

LUO Jingjing, WU Xinan, Xue Gang, Xie Zhengdong, Ye Jianbo, RONG Chengting. The pharmaceutical care by clinical pharmacists for a foot injury patient with postoperative MRSA infection[J]. Journal of Pharmaceutical Practice and Service. doi: 10.12206/j.issn.1006-0111.202102004
Citation: LUO Jingjing, WU Xinan, Xue Gang, Xie Zhengdong, Ye Jianbo, RONG Chengting. The pharmaceutical care by clinical pharmacists for a foot injury patient with postoperative MRSA infection[J]. Journal of Pharmaceutical Practice and Service. doi: 10.12206/j.issn.1006-0111.202102004
  • 外科手术部位感染(SSI)是医疗保健相关感染的常见原因[1],大多数SSI发生的时间平均为术后12 d[2]。耐甲氧西林金黄色葡萄球菌(MRSA)是指对耐药的金黄色葡萄球菌株对已经批准的所有β内酰胺类抗菌药物有交叉耐药[3]。感染MRSA外科伤口较严重的患者,建议静脉输注糖肽类、利奈唑胺或达托霉素治疗[3]。因临床应用万古霉素经验丰富,为胃肠外首选[4]。但其治疗窗窄、不良反应多、血药浓度影响因素较多等特点,根据患者临床情况实施治疗药物监测(TDM)和个体化用药显得尤为重要。笔者介绍一例临床药师对足损伤术后感染MRSA患者进行药学监护的体会。

    • 患者,男,17岁,体重60 kg,2020-05-04因“车祸致左足开放性外伤,出血30 min”入院,主要诊断为足部开放性损伤伴骨折、足部损伤、跟腱断裂。05-05行Ⅰ期清创+骨折切开复位内固定+跟腱修复+甲床修复术,术后头孢呋辛预防48 h。05-07手术切口感染,给予头孢呋辛治疗,05-08行Ⅱ期清创+创面封闭式负压引流术。05-11出现发热,体温最高38.2 ℃,炎性指标异常升高,换用万古霉素1.0 g ivgtt q12h。05-12切口分泌物培养+药敏示:MRSA、多重耐药,万古霉素敏感。05-19行Ⅲ期左足清创+带蒂皮瓣转移修复+跟腱修复术,头孢呋辛1.5 g ivgtt q8h预防感染,术后次日切口感染,体温最高38.7 ℃,换用万古霉素1.0 g ivgtt q12h抗感染治疗。其他治疗:Ⅰ~Ⅲ期术后常规氟比洛芬酯注射液镇痛3 d,Ⅲ期术后地塞米松抗炎、甘油果糖消肿、氟比洛芬酯注射液镇痛3 d,改为双氯芬酸钠胶囊。05-22万古霉素血药浓度检测为4.08 μg/ml,05-23调整万古霉素剂量为1.0 g ivgtt q8h,停用甘油果糖、地塞米松,05-26停用双氯芬酸钠胶囊。05-25、05-29复测万古霉素血药浓度为8.41、10.23 μg/ml。在增加万古霉素剂量的次日上午,患者出现面部潮红症状,调慢滴速,症状缓解至消失,未再出现类似ADR。05-29出现急性肝损伤,停用万古霉素,给予甘草酸二铵保肝治疗1周,06-04切口恢复良好,准予出院。两周后随访,肝功能恢复正常。

    • 术后第3天,患者发生足部切口感染,且为入院48 h后发生,予头孢呋辛治疗,体温、炎性指标未得到明显改善,临床药师高度怀疑为医院获得性MRSA。根据《哈里森感染病学》皮肤软组织感染治疗,对于社区或医院获得性金黄色葡萄球菌感染,对β-内酰胺类抗生素无应答,需换用抗MRSA药物治疗。临床药师建议换用万古霉素1.0 g ivgtt q12h治疗,医师采纳意见,当晚患者体温恢复正常。Ⅲ期手术预防用药,临床药师针对患者本次住院已检出MRSA,且近半年骨科MRSA检出率为62.5%,建议调整为万古霉素[5],但医师未采纳药师建议。

    • 术后第3天,出现切口红肿热痛、大量渗出、发热,诊断外科切口感染明确,选择万古霉素。临床药师根据未接受血液透析的成人胃肠外万古霉素剂量推荐表[6],结合患者体重、非重症感染、肌酐清除率指标,推荐初始剂量为1.0 g ivgtt q12h。

    • 患者05-29因出现急性肝损伤,根据《万古霉素临床应用专家共识》[4]推荐疗程为7~14 d,患者用药9 d,临床药师根据患者临床症状无明显红肿热痛,炎性指标趋于正常,可停用抗菌药物治疗。

    • 05-19行Ⅲ期术后次日,切口出现感染征象,给予万古霉素抗感染治疗。05-20至05-23患者切口感染部位症状缓解不明显,一直低热状态。临床药师建议行万古霉素血药浓度监测,同时建议停用可能影响万古霉素血药浓度的甘油果糖,并参考《万古霉素个体化给药临床药师指引》[7]调整其剂量为1.0 g ivgtt q8h。万古霉素剂量调整前血药浓度为4.08 μg/ml,调整后复测2次血药浓度分别为8.41、10.23 μg/ml。通过停用甘油果糖、TDM、调整万古霉素剂量,患者血药浓度显著升高,并达到有效治疗浓度[4]

      影响成年患者体内万古霉素的浓度因素包括年龄、中重度外周水肿、肾功能异常、肥胖及肾功能亢进等因素[8-9]。患者术后切口部位严重水肿,炎性反应明显,在一定程度上会对血液内稳态产生一定影响,导致机体代谢药物的能力也受到一定影响。万古霉素联合应用甘油果糖可能会严重影响其血药浓度,有研究显示[10],渗透性药物能促进万古霉素在体内的清除和排泄,令血药浓度降低。本例患者本身存在严重组织水肿,同时使用渗透性药物甘油果糖,可能是影响万古霉素血药浓度过低的原因。肾功能亢进的原因包括烧伤、粒细胞缺乏伴发热、脓毒血症、创伤、蛛网膜下隙出血等[11]。该患者严重创伤入院,肌酐清除率为145.94 ml/min,存在肾功能亢进,可能在一定程度上导致患者万古霉素血药浓度过低。

    • 患者在使用万古霉素增加剂量为1.0 g ivgtt q8h,次日上午出现面部、颈部微潮红。临床药师结合患者用药史,采用诺氏评估量表评价ADR关联性,评分为7分,考虑很可能为万古霉素相关性引起的红人综合征(RMS)。RMS是在万古霉素输注期间或输注结束后立即出现的潮红,由组胺介导。组胺释放量一般与输注万古霉素的剂量和输注速度有关[12]。本例患者在未调整万古霉素剂量之前,输注时间控制在60 min左右,一直未发生相关不良反应。临床药师建议先以给药速率≤10 mg/min输注(或1.0 g,输注时间≥100 min)[12],并密切监护。结果减慢滴速后,患者潮红症状消退,并未再出现RMS症状。

    • 对于肾功能正常,合并肾损伤药物且疗程较长的患者,应密切监测肾功能[4]。本例患者在Ⅰ~Ⅲ期术后,常规使用非甾体类药物镇痛,为避免增加肾损伤可能性,结合患者疼痛评分3分,临床药师建议尽早停用非甾体类药物,或换用肾功能损伤最小的阿片类镇痛药[13],医师采纳该意见。

    • 患者入院时肝功能正常,05-09开始用万古霉素1.0 g ivgtt q12h治疗,05-16查肝功示ALT 51.7 U/L,05-18停用;05-20因病情需要再次使用万古霉素1.0 g ivgtt q12h治疗,05-23调整剂量为1.0 g ivgtt q8h。05-26复查肝功示ALT 72.6.00 U/L,AST 31.8 U/L,出现转氨酶进行性小幅升高,继续万古霉素抗MRSA治疗,符合《EASL:药物性肝损伤的临床实践指南》[14]。05-29两次复查肝功示:ALT 203.8 U/L,AST 85.5 U/L;ALT 235.00 U/L,AST 102.00 U/L,提示ALT≥3倍正常值上限,出现急性肝损伤,停用万古霉素,给予甘草酸二铵保肝治疗,06-04出院并停用甘草酸二铵。06-25随访肝功能完全恢复正常。万古霉素治疗前后ALT、AST指标变化见图1

      临床药师以诺氏评估量表作ADR关联性评价,评分为9分,患者肝损害与万古霉素不良反应发生有时间上的关联,高度可能为万古霉素引起肝功能损伤。万古霉素导致肝损伤报道例数较少[15-18],以血清转氨酶升高为主[15-18],临床表现可为无症状性肝损伤或急性肝损伤。本例患者系无症状性急性肝损伤,提示关注万古霉素长疗程治疗中肝损伤ADR。

    • 临床药师作为医疗团队中的一员,在药物使用过程中,尤其在药物浓度监测和药学监护方面发挥了重要作用。在该患者治疗过程中,临床药师查阅指南、文献及药品说明书,协助医师做好抗感染治疗方案的制定,并结合临床疗效,加强抗感染治疗的药学监护,分析治疗效果不佳原因,并有针对性地提出建议与改进措施,包括调整合并用药及药物剂量,避免和减少了万古霉素相关的RMS、肝肾功能损伤不良反应对患者进一步伤害,使患者得到较好的临床获益。

Reference (18)

Catalog

    /

    DownLoad:  Full-Size Img  PowerPoint
    Return
    Return