LIU Xiao, TANG Yan, QIAN Xiao-dan
Objective: To analyze the pharmaceutical practice process of clinical pharmacists participating in the treatment of a patient with drug-resistant Klebsiella pneumoniae intracranial infection using dual β-lactam combination therapy, and provide a reference for clinical treatment of such patients in the future. Methods and Results: A 58-year-old female patient was admitted to the hospital due to "fever for 2 days", diagnosed with "liver abscess, hepatic insufficiency, electrolyte disturbance, thrombocytopenia, hypertension and type 2 diabetes mellitus". On the 1st day after admission, blood samples of the patient were collected for microbial culture, and empirical anti-infective therapy with imipenem-cilastatin sodium was initiated. On the 3rd day, percutaneous ultrasound-guided puncture and drainage of the liver abscess was performed, and pus samples were sent for culture. On the 5th day, the pus culture result indicated Klebsiella pneumoniae (susceptible). On the 7th day, the patient presented with a body temperature of 38 ℃ and mental abnormalities, with persistently elevated blood routine and inflammatory indicators, and intracranial CT examination results showed no obvious abnormalities. Clinical pharmacists considered that the patient had developed imipenem-related central nervous system adverse reactions, and central nervous system infection could not be ruled out. Therefore, they suggested adjusting the anti-infective regimen to meropenem plus amikacin, which was adopted by the clinical team. On the 10th day after admission, the patient experienced bradycardia, hypotension, poor consciousness response and neck stiffness at night, and intracranial infection was suspected. On the 11th day, the metagenomic next-generation sequencing (mNGS) result confirmed Klebsiella pneumoniae with drug-resistant genes detected. After a hospital-wide consultation, the anti-infective regimen was adjusted to meropenem plus ceftazidime-avibactam sodium plus amikacin. On the 24th day, the patient's cerebrospinal fluid (CSF) examination results improved significantly compared with the previous data; re-examination CT showed partial reduction of multiple hepatic lesions, and amikacin was discontinued. On the 31st day, the patient's maximum body temperature reached 39 ℃ with persistently high inflammatory indicators; a repeat lumbar puncture revealed positive CSF Pandy's test and an increased nucleated cell count compared with the results on the 24th day, suggesting a possible recurrence of intracranial infection. Meropenem was then discontinued, and the regimen was changed to intravenous infusion of colistimethate sodium (CMS) plus ceftazidime-avibactam sodium, combined with one intrathecal injection of CMS. A second intrathecal injection of CMS was administered on the 32nd day, and the intravenous infusion of CMS plus ceftazidime-avibactam sodium was continued thereafter. On the 35th day, the patient's body temperature decreased to 37.2 ℃; lumbar puncture showed normal CSF properties, with a significant reduction in nucleated cell count compared with the previous data. Subsequently, three blood cultures turned negative, and the patient's body temperature gradually decreased. On the 48th day, the patient was afebrile, all infection indicators returned to normal range, and a repeat lumbar puncture showed normal CSF properties. Meanwhile, the mNGS result showed 1 sequence of Klebsiella pneumoniae with no drug-resistant genes detected. The patient's condition improved, and the intracranial infection was basically controlled. Ceftazidime-avibactam sodium was discontinued on the 52nd day, and CMS was discontinued on the 59th day, after which the patient was discharged from the hospital. Conclusion: In the treatment of a patient with central nervous system infection caused by carbapenem-resistant Klebsiella pneumoniae, clinical pharmacists contributed to the continuous adjustment and optimization of anti-infective regimens by integrating pharmacokinetics/pharmacodynamics knowledge and adverse drug reaction analysis. Eventually, the patient's condition was effectively controlled with a favorable prognosis. This case can provide a reference for clinical treatment of patients with invasive Klebsiella pneumoniae liver abscess complicated with metastatic central nervous system infection, and help improve the clinical treatment level.
