GUAN Xin, ZHANG Dong-mei, QING Chen
Objective: To analyze the adjustment of anti-infective treatment regimens and the pharmaceutical care process of a hemodialysis patient who developed secondary catheter-related bloodstream infection (CRBSI) after influenza A virus infection during continuous renal replacement therapy (CRRT), and to provide a reference for clinical practice. Methods and Results: A 73-year-old female patient was admitted due to "fatigue and anorexia for 3 days". After admission, combined with her symptoms and various examination indicators, the patient was clinically diagnosed with renal failure and had dialysis indications. On the 2nd day of admission, hemodialysis was initiated. After 7 days of hemodialysis, the patient's antigen detection for influenza A virus was positive, and symptomatic treatment was given with oseltamivir phosphate at the standard dose. On the 10th day of admission, the patient developed altered mental status, delirium, high fever and chills. Clinical pharmacists were consulted. The patient was observed unconsciously touching the catheter, raising suspicion of catheter-related bacterial infection. It was recommended to send blood cultures and recheck infection markers. Meanwhile, considering that the patient's mental status changes might be related to excessive oseltamivir dose, temporary discontinuation of the drug and hemodialysis were suggested, followed by removal of the jugular vein catheter after dialysis. On the 11th day of admission, the patient's infection markers elevated. Clinical pharmacists recommended anti-infective treatment with cefazolin (1 g, q12h). In the afternoon of the same day, blood culture results revealed Gram-positive bacteria, and the patient's oxygen saturation decreased. Due to the critical condition, she was transferred to the ICU for CRRT. Clinical pharmacists were again consulted to adjust the antibacterial regimen under CRRT. Considering the patient's worsening condition and septic shock, the antibacterial drug was adjusted to vancomycin (0.5 g, q24h). During treatment, the patient experienced a drop in blood pressure, and vasopressors were administered to maintain blood pressure. On the 12th day of admission, the patient's infection symptoms and markers further deteriorated. Clinical pharmacists assessed that the original vancomycin dose was insufficient and she had concurrent pulmonary infection, recommending adjustment of the anti-infective regimen to vancomycin (0.5 g, q8h) plus meropenem (1 g, q8h). On the 13th day of admission, blood cultures revealed methicillin-resistant Staphylococcus aureus (MRSA), and the original regimen was continued. On the 14th day of admission, the patient's clinical symptoms improved, CRRT was discontinued, and the doses were adjusted to vancomycin (0.5 g, q24h) and meropenem (0.5 g, q12h). On the 18th day of admission, the patient still had intermittent fever and elevated serum creatinine. CRRT was restarted, and the doses of vancomycin and meropenem were restored to the initial CRRT doses. On the 22nd day of admission, the patient's clinical symptoms gradually improved and she was transferred to a general ward. Conclusion: For patients with diabetic chronic kidney disease undergoing hemodialysis complicated with CRBSI, CRRT is an important therapeutic modality. Since this treatment affects the in vivo pharmacokinetic and pharmacodynamic parameters of most antibacterial drugs, it is necessary for active participation of clinical pharmacists in clinical diagnosis and treatment, combining patient conditions with drug pharmacokinetic characteristics, bringing professional strengths into full play, so as to ensure safe and effective treatment regimens.
