王玥媛 陈昆 刘梦颖 方洁

摘 要 目的：探讨人类免疫缺陷病毒（HIV）患者继发耶氏肺孢子菌肺炎（PJP）重症感染患者的抗感染治疗和药学监护策略。方法：临床药师参与1例HIV合并PJP导致呼吸衰竭患者的治疗，协助医生制定给药方案，从治疗药物监测（TDM）、剂量调整、疗效观察和不良反应监测等方面进行藥学监护。结果：患者接受标准剂量复方磺胺甲噁唑（SMZ-TMP）治疗后，药物浓度达到理想靶值，症状得到了有效的控制，突发严重腹泻后SMZ-TMP监测浓度显著下降，导致病情的反复。结论：重症感染的患者病情复杂多变，临床药师运用TDM能够协助临床优化治疗方案。

关键词 复方磺胺甲噁唑 治疗药物监测 耶氏肺孢子肺炎 药学监护

中图分类号：R519.8； R512.91 文献标志码：C 文章编号：1006-1533（2020）23-0101-04

A case report of one HIV-PJP patient： discussion on pharmaceutical care

WANG Yueyuan1，2*， CHEN Kun3， LIU Mengying4， FANG Jie2**

（1. Department of Pharmacy， Personalized Drug Therapy Key Laboratory of Sichuan Province， Sichuan Academy of Medical Sciences， Sichuan Provincial Peoples Hospital， the Hospital affiliated to University of Electronic Science and Technology of China， Chengdu 610072， China； 2. Department of Pharmacy， Ruijin Hospital affiliated to School of Medicine， Shanghai Jiao Tong University， Shanghai 200025， China； 3. Department of Pharmacy， the Hospital affiliated to Southwest Medical University， Sichuan Luzhou 646000， China； 4. Department of Pharmacy， Nanjing Drum Tower Hospital affiliated to Medical College of Nanjing University， Nanjing 210008， China）

ABSTRACT Objective：To explore anti-infective treatment and pharmaceutical care strategies for a patient with severe infection of Pneumocystis jirovecii pneumonia （PJP） secondary to human immunodeficiency virus （HIV）. Methods： Clinical pharmacist participated in the treatment of a patient with respiratory failure caused by HIV combined with PJP， assisted the doctor in formulating the drug administration plan， and performed pharmaceutical care in terms of therapeutic drug monitoring（TDM）， dose adjustment， efficacy observation and adverse reaction monitoring. Results： After receiving the standard dose of trimethoprim-sulfamethoxazole （SMZ-TMP）， the drug concentration reached the target value and symptoms were controlled. However， the SMZ-TMP concentration decreased significantly after severe diarrhea， which led to the recurrence of the disease. Conclusion： Clinical pharmacists can assist the clinical physician in developing and optimizing the treatment plan by TDM since the conditions of patients with severe infections are complicated and changeable.

KEy WORDS SMZ-TMP； TDM； PJP； pharmaceutical care

耶氏肺孢子菌肺炎（Pneumocystis jirovecii pneumonia，PJP）是耶氏肺孢子菌引起的急性或亚急性肺炎，最初可能仅表现为呼吸困难，但随后出现发热、干咳，伴有明显呼吸急促，最终导致呼吸衰竭死亡[1]。耶氏肺孢子菌是一种机会性病原体，是免疫功能低下者，特别是人类免疫缺陷病毒（human immunodeficiency virus，HIV）感染导致的获得性免疫缺陷综合征（acquired immune deficiency syndrome，AIDS）患者和器官移植者、血液恶性肿瘤患者及接受免疫抑制治疗患者罹患肺炎的重要原因[2]。

随着艾滋病的流行，PJP发病率急剧上升，抗肺孢子菌预防用药和高效的抗逆转录病毒药物联合治疗（highly active antiretroviral therapy，HAART）的引入使其发病率有所下降。但其起病隐匿，疾病进展快，仍然是艾滋病相关死亡的重要原因[3]。本研究为临床藥师参与的1例HIV-PJP患者药学监护案例，现分析如下。……