1例70岁男性患者,因发热2 d,诊断为"重症肺炎、脓毒性休克、急性肾功能衰竭、慢性硬膜下血肿、脑梗死".入院后给予亚胺培南西司他丁联合利奈唑胺抗感染,因尿量减少,肌酐进一步升高,行床边连续肾脏替代疗法(CRRT)并调整亚胺培南西司他丁剂量.之后患者发生癫痫,给予抗癫痫治疗并停用亚胺培南西司他丁和利奈唑胺,采用哌拉西林他唑巴坦继续抗感染治疗,患者癫痫未再发.后患者血培养结果显示真菌感染,遂采用抗真菌治疗.在治疗期间,临床药师对行C R RT下患者的抗菌药物剂量调整给予建议,重点对亚胺培南西司他丁的剂量调整、不良反应及抗真菌药物的选择进行药学监护.经对症治疗后,患者病情好转出院.%One 70-year-old male patient with fever was diagnosed as cerebral infarction combined with severe pneumonia, septic shock, acute renal failure, chronic subdural hematoma. The patient was treated with imipenem and cilastatin combined with linezolid for anti-infection. Bedside continuous renal replacement therapy (CRRT) was executed and the dose of imipenem and cilastatin was adjusted due to the decreasing of the urine volume and the increasing of serum creatinine. Then the patient developed epilepsy, anti-epileptic treatment was executed, and imipenem and cilastatin and linezolid were withdrawn. Piperacillin and tazobactam was used for anti-infection treatment. Antifungal therapy was added according to the blood culture results. During the treatment, clinical pharmacists gave advice on adjusting the dose of antibiotics when the patient undergoing CRRT, especially for the dosage adjustment of imipenem and cilastatin and selection of antifungal drugs. After symptomatic treatment, the patient was discharged with better condition.
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