1例阴沟肠杆菌和MRSA所致复杂性 腹腔感染患者的药学监护

目的：通过参与1例胰十二指肠切除术后阴沟肠杆菌和耐甲氧西林金黄色葡萄球菌（Methicillin-resistant Staphylococcus aureus，MRSA）混合感染的药物治疗实践，探讨临床药师在复杂性腹腔感染患者抗感染治疗中的作用。方法：临床药师每天参加胰十二指肠切术后患者的医学查房，开展药学服务，并根据患者体温、腹痛、腹腔引流、血常规、血生化和药敏试验结果，提出相关药物治疗建议，并对患者进行药学监护。结果：患者术后有关感染指标升高，经验性选择头孢哌酮/舒巴坦治疗5d后，患者出现寒战发热，行引流液培养检出阴沟肠杆菌，临床药师根据药敏结果、抗菌药物特点和患者情况，建议选择亚胺培南西司他丁。医生采纳该方案治疗2d后，患者仍寒战发热，治疗4 d后，引流液同时检出阴沟肠杆菌和MRSA，药师建议调整抗感染治疗方案，加用万古霉素联合治疗，并对万古霉素的不良反应进行监护。患者治疗2w后，痊愈出院。结论：临床药师深入临床参与制定个体化抗感染治疗方案，直接面向患者提供药学服务，开展药学监护，对复杂性腹腔感染的药物治疗发挥了重要作用。

Pharmaceutical Care for a Patient with Complicated Intra-abdominal Infection Caused by Enterobacter Cloacae and Methicillin-resistant Staphylococcus Aureus by Clinical Pharmacists

Objective: To investigate the role of clinical pharmacists in the treatment for patients with complicated intra-abdominal infection, through participating drug therapy practice for infections caused by Enterobacter cloacae and methicillin-resistant Staphylococcus aureus after pancreaticoduodenectomy. Meth-ods: Clinical pharmacists participated medical ward rounds and carried out pharmaceutical ward rounds ev-eryday for a patient after pancreaticoduodenectomy, provided options for individualized medications and of-fered special pharmaceutical cares for monitoring the main drug therapy according to the results of body temperature, stomachache, peritoneal drainage, blood routine, serum biochemistry, drug sensitivity tests and clinical manifestations of the patient. Results: The patient was empirically treated with cefoperazone/sulbac-tam when the postoperative infection indicators turned positive. After five days, the patient suffered from chill and fever, Enterobacter cloacae was detected from peritoneal drainage. Clinical pharmacists suggested physicians to use imipenem/cilastatin based on the drug sensitivity test, antimicrobial characteristics and patient condition. Two days later, the patient suffered from chill and fever again. Four days later, Enter-obacter cloacae and Methicillin-resistant Staphylococcus aureus were detected simultaneously from peritoneal drainage. Clinical pharmacists suggested physicians to use vancomycin and strengthen monitoring its adverse reactions. The patient recovered and was discharged from hospital after the anti-infection treatment for two weeks. Conclusion: Clinical pharmacists provide pharmaceutical care for patients directly in clinic, such as participating in setting individualized treatment for infections, which can provide effective drug therapy for complicated intra-abdominal infection and improve the quality of medication.