病例报告：1例肾功能不全卒中并发肺炎患者抗感染治疗分析

Case Report: Analysis of Anti-Infection Treatment for a Patient with Renal Failure Stroke Complicated with Pneumonia

摘要: 目的：分析1例肾功能不全卒中并发细菌、COVID-19肺炎患者抗感染的治疗过程，为临床类似患者的抗感染治疗提供参考。方法：回顾性分析四川大学华西医院神经内科收治1例脑梗死患者的临床资料。结果：患者(男，78岁)，体型正常，BMI 24.22 kg/m²，体表面积1.41 m²。首发症状：反复头晕1月余。颅脑MRA：右侧大脑后动脉P1段局部重度狭窄，左侧椎动脉V4段、右侧颈内动脉C6段中–重度狭窄，基底动脉中度狭窄；诊断为脑卒中。根据患者病史和检查结果目前考虑慢性肾功能不全，CKD3期。其胸部CT提示存在肺部感染，体温38.0℃伴咳痰，考虑为卒中相关性肺炎，遂经验性予哌拉西林/他唑巴坦治疗；新型冠状病毒核酸检测：OF1ab/N基因扩增阳性；2 d后使用莫诺拉韦抗病毒；又2 d后，患者突发高热，且白细胞计数、中性粒细胞百分比、CRP、IL-6等感染指标明显升高，eGFR：26.75 mL/min/1.73m²，Ccr：24.78 mL/min，遂将哌拉西林/他唑巴坦改为美罗培南，但感染症状并未明显好转，且CT提示肺部病变加重；4 d后，痰标本中检出耐碳青霉烯鲍曼不动杆菌，加用替加环素抗感染；又10 d后，感染明显消退，Fib进行性降低且出现危急值：0.54 g/L，对症处理；1 d后，考虑Fib降低不排除与替加环素使用有关，建议停用替加环素及补充人纤维蛋白原；3 d后，患者感染基本消退，症状好转，Fib水平恢复，遂出院。结论：报道1例卒中相关肺部感染病例，该患者耐碳青霉烯鲍曼不动杆菌、COVID-19感染，CKD3期。卒中相关性肺炎具有病原菌谱复杂、混合感染持久的特点，并且疾病过程中病原菌往往多变；对此，临床药师应积极探寻卒中相关性肺炎的病原菌，从而及时予以针对性抗感染治疗，同时强调了药师在临床治疗中对药物不良反应识别和处理能力的重要性，同时利用专业知识进行分析和监护，提高患者用药安全性，以确保患者尽快康复。

Abstract: Objective: To analyze the anti-infective treatment process of a stroke patient with renal insufficiency complicated by bacterial and COVID-19 pneumonia, providing a reference for anti-infective treatment in clinically similar patients. Methods: A retrospective analysis was conducted on the clinical data of a patient with cerebral infarction admitted to the Department of Neurology, West China Hospital, Sichuan University. Results: The patient was a 78-year-old male with a normal body build, a BMI of 24.22 kg/m², and a body surface area of 1.41 m². Initial symptoms included recurrent dizziness for more than a month. Cranial MRA revealed local severe stenosis of the P1 segment of the right posterior cerebral artery, moderate-to-severe stenosis of the V4 segment of the left vertebral artery and the C6 segment of the right internal carotid artery, and moderate stenosis of the basilar artery; a diagnosis of stroke was made. Based on the patient’s medical history and examination results, chronic renal insufficiency, stage CKD3, was currently considered. Chest CT indicated lung infection, with a body temperature of 38.0˚C accompanied by cough with expectoration, suggesting stroke-associated pneumonia, and empirical treatment with piperacillin/tazobactam was initiated; nucleic acid testing for SARS-CoV-2 showed positive amplification of the OF1ab/N gene; antiviral treatment with molnupiravir was administered 2 days later. Two days thereafter, the patient suddenly developed high fever, and infection indicators such as white blood cell count, neutrophil percentage, CRP, and IL-6 increased significantly, with an eGFR of 26.75 mL/min/1.73m² and Ccr of 24.78 mL/min. Piperacillin/tazobactam was then switched to meropenem, but the infectious symptoms did not improve significantly, and CT showed worsening lung lesions. Four days later, carbapenem-resistant Acinetobacter baumannii was detected in sputum samples, and tigecycline was added for anti-infective treatment. Ten days after that, the infection subsided significantly, with Fib progressively decreasing to a critical value of 0.54 g/L, which was treated symptomatically. One day later, considering that the decrease in Fib could not be ruled out as related to the use of tigecycline, it was recommended to discontinue tigecycline and supplement human fibrinogen. Three days later, the patient’s infection had basically subsided, symptoms improved, and Fib levels recovered, leading to discharge. Conclusion: This report presents a case of stroke-associated lung infection in a patient with carbapenem-resistant Acinetobacter baumannii, COVID-19 infection, and stage CKD3. Stroke-associated pneumonia is characterized by a complex spectrum of pathogenic bacteria and persistent mixed infections, and the pathogenic bacteria often change during the course of the disease. In response, clinical pharmacists should actively seek out the pathogens of stroke-associated pneumonia to promptly provide targeted anti-infective treatment. At the same time, the importance of pharmacists’ ability to identify and manage adverse drug reactions in clinical treatment is emphasized, utilizing professional knowledge for analysis and monitoring to improve patient medication safety and ensure their rapid recovery.