目的 介绍临床药师对1 例肾移植术后严重根霉菌感染患者开展药学服务，达到较好的效果。方法 临床药师参与1例肾移植术后严重根霉菌感染患者的药物治疗工作，从抗微生物治疗的角度和对移植肾的保护角度推荐患者使用泊沙康唑治疗，同时结合该药的药动学特点、药物相互作用和患者的病情等因素，对药物治疗方案进行优化。结果 使用泊沙康唑口服混悬液200 mg qid，与肠内营养液混合给药，患者根霉菌感染得到控制;根据泊沙康唑与他克莫司药物相互作用特点和患者CYP3A5基因型检测结果调整他克莫司用量，整个治疗期间，患者他克莫司血药浓度绝大部分时间控制在4.8~6.7 μg·L-1之间，保证了移植肾的安全;同时，通过调整泊沙康唑服药方法、减少麦考酚钠的剂量和补充微生态制剂等措施减轻了患者的腹泻。结论 肾移植术后发生严重感染的患者，药物治疗一般比较复杂。临床药师可对此类特殊人群开展药学服务，通过治疗药物监测及药动学知识分析，发挥专业特长，促进此类患者获得最佳的药物治疗。
Abstract
OBJECTIVE To introduce the pharmaceutical care for one patient with severe infection caused by Rhizopus spp after kidney transplantation which achieved a better therapeutic effect. METHODS According to the activity of zygomycetous, clinical pharmacists recommended the patient using posaconazole to treat Rhizopus spp infection which has less kidney injury. Clinical pharmacists optimized the treatment schemes with considering the pathophysiological conditions of the patient , the pharmacokinetic characteristics of the drug and metabolic drug interactions. RESULTS The Rhizopus spp infection was controlled using posaconazole oral suspension 200mg qid mixed with enteral nutrition. According to adjust the amount of tacrolimus by the plasma concentration and CYP3A5 genotype test result ,the tacrolimus concentration was most time maintained 4.8-6.7 μg·L-1 during the treatment ,which ensure the safety of the transplanted kidney. The diarrhea was reduced by adjusting the methods of taking posaconazole, reducing the dose of mycophenolate and adding microecologics. CONCLUSIONS Drug treatment is generally complex for the patient with severe infection after renal transplantation. So, clinical pharmacists can carry out pharmaceutical care for such special patients for safety and effectiveness, through therapeutic drug monitoring and knowledge of pharmacokinetics to promote such patients to get the optimal drug treatment.
关键词
临床药师 /
药学服务 /
肾移植 /
根霉菌感染 /
泊沙康唑
{{custom_keyword}} /
Key words
clinical pharmacist /
pharmaceutical care /
kidney transplantation /
Rhizopus spp infection /
posaconazole
{{custom_keyword}} /
中图分类号：
R969
{{custom_clc.code}}
({{custom_clc.text}})
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
参考文献
[1] HU Z Q, ZHAO J Y, FANG W, et al. Retrospective analysis of hepatitis complicated with zygomycosis in mainland China : a review of 19 cases. Chin J Mycol(中国真菌学杂志), 2015, 10 (1): 31-34.
[2] CORNELY O A, ARIKAN-AKDAGLI S, DANNAOUI E, et al. ESCMID and ECMM joint clinical guidelines for the diagnosis and management of mucormycosis 2013. Clin Microbiol Infect, 2014, 20 (3): 5-26.
[3] WANG S B, WAN Z, LI R Y, et al. In vitro activity of posaconazole against 43 clinical isolates of zygomycetous fungi by E-test. Chin J Mycol(中国真菌学杂志),2012, 7 (3): 142-145.
[4] Antibiotic Guidelines 2015-2016: Treatment Recommendations For Adult Inpatients. 2015:1-164.
[5] COURTNEY R, SANSONE A, SMITH W, et al. Posaconazole pharmacokinetics, safety, and tolerability in subjects with varying degrees of chronic renal disease. J Clin Pharmacol, 2005, 45(2):185-192.
[6] MA X, ZHAO L,WANG X X, et al. Advances in research on pharmacokinetic characteristics and therapeutic drug monitoring for the antifungal extended-spectrum posaconazole. Chin Pharm J(中国药学杂志), 2016, 51(6):433-436.
[7] COURTNEY R, PAI S, LAUGHLIN M, et al. Pharmacokinetics, safety, and tolerability of oral posaconazole administered in single and multiple doses in healthy adults. Antimicrob Agents Chemother ,2003,47(9): 2788-2795.
[8] EZZET F, WEXLER D, COURTNEY R, et al. Oral bioavailability of posaconazole in fasted healthy subjects. Clin Pharmacokinet ,2005,44 (2): 211-220.
[9] KRISHNA G, MOTON A, MA L, et al. Pharmacokinetics and absorption of posaconazole oral suspension under various gastric conditions in healthy volunteers. Antimicrob Agents Chemother, 2009, 53(3): 958-966.
WEXLER D, COURTNEY R, RICHARDS W, et al. Effect of posaconazole on cytochrome P450 enzymes: a randomized, open-label, two-way crossover study. Eur J Pharm Sci, 2004, 21(5):645-653.
RAAD I I, GRAYBILL J R, BUSTAMANTE A B, et al. Safety of long-term oral posaconazole use in the treatment of refractory invasive fungal infections. Clin Infect Dis, 2006 ,42(12):1726-1734.
SANSONE-PARSONS A, KRISHNA G, MARTINHO M, et al. Effect of oral posaconazole on the pharmacokinetics of cyclosporine and tacrolimus. Pharmacotherapy, 2007, 27(6): 825-834.
FENG G W, GUO T, LI J F, et al. CYP3A5 gene polymorphism and individualized administration of tacrolimus after kidney transplantation. Chin J Organ Transplant (中华器官移植杂志), 2013, 34 (13): 647-650.
SUN W, GUO H B, XIE Z L, et al. Association factors analysis of diarrhea in patients receiving kidney transplantation. J Peking Univ Health Sci (北京大学学报:医学版), 2013,45(5):779-781.
SPAD O F,GERHARDT J,GUIMA ES T,et al. Incidence of diarrhea by clostridium difficile in hematologic patients and hematopoietic stem cell transplantation patients: risk factors for severe forms and death. Rev Inst Med Trop Sao Paulo,2014,56(4): 325-331.
KNECHT H, NEULINGER S C, HEINSEN F A, et al. Effects of β-lactam antibiotics and fluoroquinolones on human gut microbiota in relation to clostridium difficile associated diarrhea. PLoS One, 2014, 9(2): e89417. doi: 10. 1371/journal. pone. 0089417.
SI J G, SUN M. Application of microecological modulators in prevention of antibiotic-associated diarrhea . J China Pharm(中国药房), 2014,25(38):3624-3626.
{{custom_fnGroup.title_cn}}
脚注
{{custom_fn.content}}
PDF(1093 KB)
