万古霉素治疗革兰阳性球菌血流感染患者的血药浓度监测

摘要

目的 了解本院革兰阳性球菌血流感染患者万古霉素的临床应用及血清谷浓度的监测.方法 采用荧光偏振免疫偏振法测定万古霉素血清谷浓度,并结合住院患者的临床资料(基础疾病、病原学结果、万古霉素血清谷浓度、疗效、肾功能情况等),对血流感染革兰阳性球菌并应用万古霉素的25例患者进行回顾性分析.结果 血流感染耐甲氧西林金黄色葡萄球菌(MRSA)11例(44.0%),屎肠球菌14例(56.0%);临床治愈率32.0%.25例患者共进行万古霉素血清谷浓度测定38例次,血清谷浓度范围2.99~39.1 μg/mL,均值(14.96±7.83)μg/mL,其中达到靶浓度15~20 μg/mL者8例(21.0%).临床治愈组与临床无效组万古霉素血清谷浓度分别为(14.69±7.20)、(15.13±8.53)μg/mL(P=0.85).肾毒性发生6例(24.0%),APACHE Ⅱ评分均值17分,均为临床无效组.11例MRSA血流感染中,1例万古霉素最低抑菌浓度(MIC)值为2 mg/L,其余万古霉素MIC值均为1 mg/L;临床治愈组万古霉素曲线下面积(AUC)与MIC浓度比值(AUC/MIC)为209±114.结论 按照指南的标准,25例血流感染患者万古霉素血清谷浓度达标率低,需加强对这一类患者血清谷浓度的监测力度,并随时调整用药,给出个体化的用药方案.%Objective To investigate the clinical application and serum trough concentration monitoring of vancomycin in patients with Gram positive coccus bloodstream infection in our hospital.Methods The clinical information,including primary diseases,bacteriological culture,serum trough concentration of vancomycin,clinical efficacy and renal function in 25 patients with Gram positive coccus bloodstream infection treated by vancomycin were analyzed retrospectively.Results The 25 patients were found with Gram positive coccus bloodstream infection,including methicillin-resistant Staphylococcus aureus in 11 patients (44.0%) and Enterococcus faecium in 14 patients (56.0%).All patients were treated by vancomycin and 8 patients were cured(32%).Serum trough concentration of vancomycin was tested 38 times by fluorescence polarization immunoassay.The median of serum trough concentration was 14.96±7.83 (ranging 2.99~39.1)μg/mL.The guideline-recommended target trough concentration of 15~20 μg/mL was reached only in 8 patients (21.0%).The serum trough concentration of vancomycin was of no difference between the clinical cure group [(14.69±7.20)μg/mL] and clinical failure group [(15.13±8.53)μg/mL],P=0.85.Six patients in clinical failure group (24.0%)experienced nephrotoxicity and their average value of APACHE Ⅱ was 17.In 11 patients with MRSA infection,minimum bacteriostasis concentration (MIC) of vancomycin was 2 mg/L in only one patient and 1 mg/L in others.Area under curve(AUC)/ MIC in clinical cure group was 209±114.Conclusion The rate of serum trough concentration achieving guideline-recommended target of 15~20 μg/mL is low.It is important to pay more attention to the monitoring of the serum trough concentration in patients with bloodstream infection and achieve an ideal individualized administration according to the results.