抗生素敏感性与临床决策的困境：多重耐药铜绿假单胞菌血流感染报告一例

doi:10.3877/cma.j.issn.2096-1537.2024.07.23-0002

目的

报告1例多重耐药铜绿假单胞菌（MDRPA）血流感染患者的治疗过程，探讨如何以药敏试验结果与治疗药物监测（TDM）指导抗生素药物选择和剂量。

方法

1例老年脑脓肿致MDRPA血流感染患者，在治疗过程中，经验性使用头孢他啶-阿维巴坦（CAZ-AVI）治疗感染。

结果

患者临床症状得到改善。但后续的细菌药敏试验表明该细菌对CAZ-AVI具有耐药性。考虑到临床治疗容错性低，治疗改为敏感的多黏菌素B 1 mg/kg维持剂量，TDM显示AUC _{24 h, ss}已达到65.5 mg · h/L。然而，治疗6 d后临床症状并未改善。面对这一复杂局面，在临床医师、药理学家、微生物学家的通力合作下，多黏菌素B剂量增加至1.4 mg/kg，AUC _{24 h，ss}为98.6 mg · h/L，最终治疗成功，病原菌被根除。

结论

基于临床疗效反馈，以药敏结果精准解读及TDM严密监测为前提的多学科诊疗模式（MDT）有助于科学规范的抗感染临床决策的制订，并能促进患者的康复进程。

关键词: 治疗药物监测, 药代动力学/药效学, 多学科治疗, 多重耐药铜绿假单胞菌, 血流感染

Objective

To report the treatment process of a patient with multiple resistant Pseudomonas aeruginosa to guide antibiotic drug selection and dosage with antimicrobial susceptibility testing and precision therapeutic drug monitoring (TDM).

Methods

The treatment process of one elderly with multidrug-resistant Pseudomonas aeruginosa (MDRPA) bloodstream infection caused by a cerebral abscess was reported. During the treatment process, empirical therapy with ceftazidime-avibactam (CAZ-AVI) was initially used.

Results

The patient showed an improvement in her clinical symptoms. However, subsequent bacterial susceptibility testing revealed resistance to CAZ-AVI. Considering the low clinical tolerance for treatment modification, the therapy was switched to the sensitive agent polymyxin B at a maintenance dose of 1 mg/kg. TDM indicated an achieved AUC_{24 h, ss} of 65.5 mg·h/L. However, after 6 days of treatment, there was no improvement in clinical symptoms. Faced with this complex situation, a collaborative effort among the clinical physician, pharmacologist, and microbiologist led to an increase in the polymyxin B dose to 1.4 mg/kg, resulting in an AUC_{24 h, ss} of 98.6 mg·h/L. Ultimately, the treatment was successful, and the pathogen was eradicated.

Conclusion

Within the framework of scientific and regulated medication management, a collaborative multidisciplinary treatment (MDT) approach enhances the patient's rehabilitation process. The doctor's clinical expertise, guidance from TDM and pharmacokinetics/pharmacodynamics experts, and the antimicrobial susceptibility results provided by the clinical microbiology laboratory collectively inform the treatment direction.

Key words: Therapeutic drug monitoring, Pharmacokinetics/pharmacodynamics, Multidisciplinary treatment, Multi-drug-resistant Pseudomonas aeruginosa, Bloodstream infection

表1 分离自血液样本的铜绿假单胞菌药物敏感试验

抗生素	AMK	PMBa	FEP	CAZ	TZP	SCF	TGC	IPM	MEM	CIP	LEV	CAZ-AVI
MIC（mg/L）	8	1	≥ 32	≥ 64	≥ 128	≥ 64/3	>64	≥ 16	≥ 16	8	≥ 8	16/4
解读		S	R	R	R	R	-	R	R	R	R	R

表1 分离自血液样本的铜绿假单胞菌药物敏感试验

抗生素	AMK	PMBa	FEP	CAZ	TZP	SCF	TGC	IPM	MEM	CIP	LEV	CAZ-AVI
MIC（mg/L）	8	1	≥ 32	≥ 64	≥ 128	≥ 64/3	>64	≥ 16	≥ 16	8	≥ 8	16/4
解读		S	R	R	R	R	-	R	R	R	R	R

图1 患者WBC、CRP、PCT、体温、SCr和药物治疗的时间线。PMB TDM 1峰浓度：4.30 mg/L，谷浓度：1.48 mg/L，AUC _{24 h，ss}＝65.5 mg · h/L；PMB TDM 2峰浓度：6.24 mg/L，谷浓度：2.49 mg/L，AUC _{24 h，ss}＝98.6 mg · h/L注：TEMP为；WBC为白细胞；CRP为C反应蛋白；PCT为降钙素原；SCr为血肌酐；CAZ-AVI为头孢他啶-阿维巴坦；PMB为多黏菌素B；TDM为治疗药物监测

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Navigating the challenges of antibiotic sensitivity and clinical decision-making: a case study on bloodstream infection caused by multidrug-resistant Pseudomonas aeruginosa

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Navigating the challenges of antibiotic sensitivity and clinical decision-making: a case study on bloodstream infection caused by multidrug-resistant Pseudomonas aeruginosa