临床药师参与1例重症恙虫病致混合性休克的药学实践  

Practice of clinical pharmacist participating in the treatment of a case of mixed shock caused by severe scrub typhus

作　　者：黄小艳 谢静文[1,2] 夏延哲 李佳[3] HUANG Xiaoyan;XIE Jingwen;XIA Yanzhe;LI Jia(Dept.of Pharmacy,the Sixth Affiliated Hospital of Sun Yat-sen University,Guangzhou 510655,China;Guangzhou Huangpu District Zhongliu Institute for Biomedical Innovation,Guangzhou 510655,China;Dept.of Pharmacy,the First Affiliated Hospital of Sun Yat-sen University,Guangzhou 510080,China)

机构地区：[1]中山大学附属第六医院药学部,广州510655 [2]广州市黄埔区中六生物医学创新研究院,广州510655 [3]中山大学附属第一医院药学部,广州510080

出　　处：《中国药房》2025年第5期600-605,共6页China Pharmacy

基　　金：广东省医院协会医院药学科研专项(No.YXKY202212);广东省药学会科学研究基金立项项目(No.2023KJ20)。

摘　　要：目的为重症恙虫病患者的抗感染方案调整、不良反应识别及个体化药学监护提供参考。方法临床药师参与1例重症恙虫病致混合性休克并行连续性肾脏替代治疗及体外膜肺氧合的患者抗感染的药学监护过程。患者初始给予美罗培南(1 g,q12 h,ivdrip)联合多西环素(0.1 g,q12 h,po)治疗,因其肠道功能差,后改为美罗培南(1 g,q8 h,ivdrip)联合奥马环素(100 mg,qd,ivdrip)治疗。患者情况逐渐变差,感染未受控制,临床药师建议临床医生将抗感染方案调整为美罗培南(2 g,q8 h,ivdrip)联合替加环素(100 mg首剂;50 mg,q12 h维持;ivdrip)。临床医生采纳临床药师的建议。治疗后患者症状好转,感染指标明显下降,感染受控。但因患者胆红素持续上升,为减少药物性肝损伤风险,临床药师建议临床医生可将替加环素替换为阿奇霉素(0.5 g,qd,ivdrip)。结果治疗后肺泡灌洗液及血标本宏基因组高通量测序提示患者恙虫病东方体被完全清除。结论替加环素是重症恙虫病患者的一个有效选择。对于极危重的恙虫病患者,采用替加环素联合阿奇霉素治疗可能是清除恙虫病东方体更有效的方案。OBJECTIVE To provide valuable insights for the adjustment of anti-infectious regimens,identification of adverse reactions,and individualized pharmaceutical care in patients with critically severe scrub typhus.METHODS Clinical pharmacists actively participated in the pharmaceutical care process for a patient with severe scrub typhus leading to mixed shock undergoing continuous renal replacement therapy and extracorporeal membrane oxygenation.Initially,the patient received meropenem(1 g,q12 h,ivdrip),in combination with doxycycline(0.1 g,q12 h,po),which was later switched to meropenem(1 g,q8 h,ivdrip)along with omacycline(100 mg,qd,ivdrip)due to impaired gastrointestinal function.However,as the patient’s condition progressively deteriorated and the infection became uncontrolled,the clinical pharmacists recommended that the clinicians adjust the anti-infective regimen to meropenem(2 g,q8 h,ivdrip)combined with tigecycline(100 mg for first dose;50 mg,q12 h for maintenance;ivdrip).The clinicians followed the advice of the clinical pharmacists.After treatment,the patient’s symptoms exhibited significant improvement,accompanied by a notable decrease in inflammatory markers,indicating that the infection had been successfully controlled.However,due to continuously increasing bilirubin levels,in order to reduce the risk of drug-induced liver injury,the clinicians changed tigecycline to azithromycin(0.5 g,qd,ivdrip)following the recommendation of the clinical pharmacists.RESULTS Ultimately,metagenomic next-generation sequencing of the bronchoalveolar lavage fluid and blood specimens indicated that Orientia tsutsugamushi had been completely eradicated in the patient.CONCLUSIONS Tigecycline may be a viable therapeutic choice for patients with severe scrub typhus.In the context of critically ill patients with scrub typhus,combining tigecycline with azithromycin might potentially enhance the efficacy in eliminating Orientia tsutsugamushi.

关 键 词：恙虫病 脓毒症休克 心源性休克 替加环素 阿奇霉素 药学监护 危重症 

分 类 号：R969.3[医药卫生—药理学]