1例重症肺炎合并感染性心内膜炎患者的药学监护  

Pharmaceutical care on a severe infectious endocarditis complicated with pneumonia

作　　者：向道春 程刚英[1] 赖永继 周庆[1] 刘珏[1] 王奕[1] 邓艾平[1] XIANG Dao-chun;CHENG Gang-ying;LAI Yong-ji;ZHOU Qing;LIU Jue;WANG Yi;DENG Ai-ping(Department of Pharmacy,the Central Hospital of Wuhan,Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430014,China)

机构地区：[1]华中科技大学同济医学院附属武汉中心医院药学部

出　　处：《中国药物应用与监测》2019年第4期219-222,共4页Chinese Journal of Drug Application and Monitoring

基　　金：国家自然科学基金青年项目（81502943)

摘　　要：1例23岁男性患者,因“发热咯血4 d”入院,诊断为感染性心内膜炎性赘生物,二尖瓣脱垂伴关闭不全,行二尖机械瓣置换术,术后给予维持心率、抗凝、抗感染等对症支持治疗。抗凝治疗期间患者INR升高至3.04,感染控制不佳,一度出现谵妄等精神症状。临床药师查阅相关文献,发现胺碘酮、伏立康唑均通过抑制CYP2C9对华法林的代谢产生影响,遂结合患者病情,建议下调华法林剂量;考虑亚胺培南导致精神异常的可能性大,建议换用美罗培南;术后8 d感染仍未控制,建议监测万古霉素血药浓度并结合患者病理生理状态调整其剂量。经过一系列药物调整,患者恢复良好出院。A 23-year-old male patient was admitted to hospital mainly because of fever and hemoptysis for 4 days,and the patient was diagnosed with infectious endocarditis with vegetation and mitral valve prolapse with incomplete closure.Systematic treatments including maintaining heart rate,anticoagulation,and anti-infection were given to him after mitral mechanical valve replacement.During the treatment,the INR value of the patient increased to 3.04,the patient developed delirium and the infection was uncontrolled.Considering that amiodarone and voriconazole could enhance the efficacy of warfarin through inhibiting the activity of CYP2C9,pharmacists suggested reducing the dosage of warfarin.The imipenem was switched to meropenem because of the risk of psychiatric disorder induced by imipenem.The vancomycin concentration was monitored and the dose was adjusted combined with the patient's pathophysiological status due to uncontrolled infection after operation.After a series of drug adjustments,the patient was discharged in a good condition after the infection was controlled.

关 键 词：感染性心内膜炎 抗凝 抗感染 药学监护 

分 类 号：R969.4[医药卫生—药理学]