目的:分析 1 例立克次体相关性脓毒性休克患者抗感染治疗的药学监护过程,为临床立克次体所致严重感染的诊断和治疗提供参考。方法与结果:该患者 6 d 前无明显诱因情况下出现发热和干咳,1 d 前又出现呼吸困难,入院检查显示降钙素原（3.23 ng/mL）和 C 反应蛋白（120.4 mg/L）明显升高,遂临床医生予以亚胺培南-西司他丁钠、左氧氟沙星、利巴韦林经验性抗感染治疗;第 2 天,患者表现出脓毒性休克症状,临床药师会诊后建议将抗感染治疗方案调整为美罗培南和阿奇霉素;第 4 日,患者血标本的宏基因组二代测序（metagenomic next-generation sequencing,mNGS）检测结果显示日本立克次体呈阳性,而痰标本的 mNGS 结果显示肺炎克雷伯菌、缓症链球菌、肺炎链球菌和热带假丝酵母呈阳性,临床药师认为日本立克次体为病原菌,而其他则为定植菌,故建议将抗感染治疗方案改为多西环素,但临床医生出于稳妥起见加用了哌拉西林-他唑巴坦钠;3 d 后,患者体温恢复正常,感染指标和相关症状亦明显改善,并在不久后出院。结论:立克次体引起脓毒性休克情况相对较为少见,因而临床相对容易忽视,临床药师在开展药学监护时应综合分析患者的临床表现、检查结果和用药史,协助临床医生尽快确定感染的病原菌,从而有针对性地开展抗感染治疗,以保证患者快速康复。
Abstract
Objective: To analyze the pharmaceutical care process of anti-infective treatment in a patient with Rickettsia-associated septic shock, and provide reference for the diagnosis and treatment of serious infection caused by Rickettsia in clinical practice. Methods and Results: The patient developed fever and dry cough without obvious inducement 6 days ago, and dyspnea 1 day ago. The examination at admission showed that the procalcitonin (3.23 ng/mL) and C-reactive protein (120.4 mg/L) levels increased obviously, so the clinician gave empiric anti-infective treatment with imipenem-cilastatin sodium, levofloxacin, and ribavirin; on the 2nd day, the patient showed symptoms of septic shock, and after consultation with the clinical pharmacist, it was suggested that the anti-infective treatment regimen was adjust to meropenem and azithromycin; on the 4th day, the metagenomic next-generation sequencing (mNGS) test results of the patient's blood samples showed positive for Rickettsia japonica, while the mNGS results of the sputum samples showed positive for Klebsiella pneumoniae, Streptococcus mitis, Streptococcus pneumoniae and Candida tropicalis. The clinical pharmacists believed that Rickettsia japonicum was pathogenic bacteria and the others were colonized bacteria, so it was suggested that the anti-infective treatment regimen was changed to doxycycline, but the clinician added piperacillin-tazobactam sodium for the safety purpose; 3 days later, the patient's body temperature returned to normal, infection indicators and related symptoms were obviously improved, and the patient was discharged from the hospital soon. Conclusion: Septic shock caused by Rickettsia is relatively rare, so it is easily ignored in clinical practice. When carrying out the pharmaceutical care, clinical pharmacists should comprehensively analyze the patient's clinical manifestations, examination results and medication history, assist clinicians in identifying the pathogenic bacteria of infection as quickly as possible, so that the targeted anti-infective treatment is carried out to ensure rapid recovery of the patient.
关键词
立克次体 /
脓毒性休克 /
药学监护 /
临床药师
{{custom_keyword}} /
Key words
Rickettsia /
septic shock /
pharmaceutical care /
clinical pharmacist
{{custom_keyword}} /
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
参考文献
[1] Kollef MH, Shorr AF, Bassetti M, et al.Timing of antibiotic therapy in the ICU[J].Crit Care, 2021, 25(1): 1-10.
[2] Evans L, Rhodes A, Alhazzani W, et al.Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021[J]. Intensive Care Med, 2021, 47(11): 1181-1247.
[3] Zhang X, Geng JJ, Du J, et al.Molecular identification of Rickettsia species in Haemaphysalis ticks collected from southwest China[J]. Vector Borne Zoonotic Dis, 2018, 18(12): 663-668.
[4] Abdad MY, Abou Abdallah R, Fournier PE, et al.A concise review of the epidemiology and diagnostics of rickettsioses: Rickettsia and Orientia spp[J]. J Clin Microbiol, 2018, 56(8): e01728-e01717.
[5] 王媛媛,李孝锋,张文静,等. 危重型日本斑点热 1 例[J]. 中华传染病杂志,2022,40(2):108-110.
[6] Raoult D, Lakos A, Fenollar F, et al.Spotless rickettsiosis caused by Rickettsia slovaca and associated with Dermacentor ticks[J]. Clin Infect Dis, 2002, 34(10): 1331-1336.
[7] Strich JR, Heil EL, Masur H.Considerations for empiric antimicrobial therapy in Sepsis and septic shock in an era of antimicrobial resistance[J]. J Infect Dis, 2020, 222(Supplement 2): S119-S131.
[8] 北京医学会检验医学分会. 重症社区获得性肺炎病原微生物实验室诊断专家共识[J]. 中华医学杂志,2020,100(19):1459-1464.
[9] 曾雪梅,李睿,陈春梅,等. 美罗培南治疗重症肺部感染临床疗效的循证医学研究[J]. 中华医院感染学杂志,2019,29(6):814-820.
[10] Salmon-Rousseau A, Martins C, Blot M, et al.Comparative review of imipenem/cilastatin versus meropenem[J]. Médecine Maladies Infect, 2020, 50(4): 316-322.
[11] 国家卫生健康委,合理用药专家委员会.全国细菌耐药监测网. 2020 年全国细菌耐药监测报告[J]. 中国合理用药探索,2021,18(3):1-11.
[12] Firth A, Prathapan P.Azithromycin: the first broad-spectrum therapeutic[J]. Eur J Med Chem, 2020, 207: 112739.
[13] Tabah A, Cotta MO, Garnacho-Montero J, et al.A systematic review of the definitions, determinants, and clinical outcomes of antimicrobial de-escalation in the intensive care unit[J]. Clin Infect Dis, 2016, 62(8): 1009-1017.
[14] Timsit JF, Lipman J, Bassetti M.Antimicrobial de-escalation is part of appropriate antibiotic usage in ICU[J].Intensive Care Med, 2020, 46(5): 1039-1042.
[15] Gillespie JJ, Kaur SJ, Rahman MS, et al.Secretome of obligate intracellular Rickettsia[J]. FEMS Microbiol Rev, 2015, 39(1): 47-80.
[16] 《抗菌药物临床应用指导原则》修订工作组.抗菌药物临床应用指导原则[M].2015 年版.北京:人民卫生出版社,2015.
[17] 刘凯雄,瞿介明. 关于《成人社区获得性肺炎基层诊疗指南(2018 年)》的几点说明[J]. 中华全科医师杂志,2019,18(2):101-103.
{{custom_fnGroup.title_cn}}
脚注
{{custom_fn.content}}
PDF(1597 KB)
