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·药师与药学服务·

伏立康唑联合米卡芬净治疗曲霉菌性心内膜炎患者的药学监护 Δ

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张新茹 ，王冬雪，于 玲，李 馨（吉林大学第二医院药学部，长春 130041）
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中图分类号 R542.4 1；R969.3 文献标志码 A 文章编号 1001-0408（2022）04-0503-04
DOI 10.6039/j.issn.1001-0408.2022.04.20

摘 要 目的 为真菌性心内膜炎的临床诊疗提供思路。方法 对临床药师全程参与的１例曲霉菌性心内膜炎患者的诊断和治疗
过程进行分析。临床药师建议行血宏基因组二代测序（mNGS）检测和血培养来辅助真菌性心内膜炎的诊断；从药物的作用机制、
作用靶点和安全性等方面考虑，建议采用伏立康唑联合米卡芬净进行抗真菌治疗；结合患者病情，权衡利弊，将米卡芬净调整至每
天300 mg；预防、评估和处理治疗过程中的药物不良反应，并对患者进行用药指导和出院长期随访。结果 医师采纳了临床药师的
建议。患者血 mNGS 检出烟曲霉，为其早期诊断和个体化治疗争取了时间；采用伏立康唑联合米卡芬净进行抗真菌治疗 1 个月
后，患者病情得到了良好控制；给予丁二磺酸腺苷蛋氨酸治疗后，患者碱性磷酸酶和γ-谷氨酰转肽酶恢复正常；在临床药师的用药
指导、教育和出院随访协助下，患者的用药依从性良好，病情平稳。结论 临床药师参与了该患者的诊疗过程，为其制订了个体化
的抗感染治疗方案并取得了良好的效果，体现了临床药师的专业能力和服务水平，为真菌性心内膜炎的临床诊疗提供了思路。
关键词 真菌性心内膜炎；曲霉菌性心内膜炎；烟曲霉；伏立康唑；米卡芬净；宏基因组二代测序；药学监护；临床药师
Pharmaceutical care of voriconazole combined with micafungin in the treatment of aspergillus endocarditis
ZHANG Xinru，WANG Dongxue，YU Ling，LI Xin（Dept. of Pharmacy，the Second Hospital of Jilin University，
Changchun 130041，China）

ABSTRACT OBJECTIVE To provide ideas for diagnosis and treatment of fungal endocarditis. METHODS The diagnosis and
treatment of 1 case of aspergillus endocarditis participated by clinical pharmacists were analyzed. Clinical pharmacists suggested that
blood macrogenomic next-generation sequencing（mNGS）detection and blood microbial culture should be performed to assist in
the diagnosis of fungal endocarditis； considering the mechanism， target and safety of the drug， it was suggested to use
voriconazole combined with micafungin for antifungal treatment；through combining with the patient’s condition and weighing up
the pros and cons，the dose of micafungin was adjusted to 300 mg per day；clinical pharmacists prevented，evaluated and dealt
with adverse drug reactions during treatment，and also provided medication guidance and long-term follow-up for the patient after
discharge. RESULTS The clinician adopted the advice of the clinical pharmacists. Aspergillus fumigatus was detected in blood
mNGS，which bought time for early diagnosis and individualized treatment of the patient. After 1 month treatment of voriconazole
combined with micafungin，the patient’s condition was well controlled. The alkaline phosphatase and γ-glutamyl transferase of the
patient returned to normal after treatment with adenosylmethionine succinate. With the help of medication guidance，education and
discharge follow-up of clinical pharmacists，the medication compliance of the patient was good and the condition was stable.
CONCLUSIONS The clinical pharmacists participate in the diagnosis and treatment process of the patient， formulate an
individualized anti-infective treatment plan for the patient and achieve good results，which reflect the professional ability and
service level of the clinical pharmacist，and provide ideas for the clinical treatment of fungal endocarditis.
KEYWORDS fungal endocarditis；aspergillus endocarditis；Aspergillus fumigatus；voriconazole；micafungin；macrogenomic
next-generation sequencing；pharmaceutical care；clinical pharmacist

真菌性心内膜炎（fungal endocarditis，FE）是指真菌 性心内膜炎（infective endocarditis，IE）中较少见的一种，
循血行途径直接感染心脏瓣膜、心室壁内膜或邻近大动 占所有 IE 的 1％～6％ ；但 FE 的病死率极高，尤其是曲
[2]
[1]
脉内膜，并伴赘生物形成的一种感染疾病 。FE是感染 霉菌引起的FE，病死率高达50％～96％ 。FE 的临床表
[3]
现与细菌性心内膜炎相比没有明显差异，缺乏特异性，
Δ 基金项目：吉林省医疗卫生人才专项项目（No.2019SCZT086）
临床诊断相当困难，且目前最优治疗方案也存在争议，
＊ 副 主 任 药 师 ，博 士 。 研 究 方 向 ：临 床 药 学 。 电 话 ：0431-
因此其诊断和治疗均极具挑战性。本文拟对1例曲霉菌
81136601。E-mail：zhangxinru0130@163.com
# 通信作者：副主任药师，博士。研究方向：临床药学。电话： 性心内膜炎的诊断和治疗过程进行分析，并就临床药师
0431-81136601。E-mail：2662810@qq.com 如何在该病治疗过程中为患者制订个体化抗感染方案

中国药房 2022年第33卷第4期 China Pharmacy 2022 Vol. 33 No. 4 ·503 ·