疑似Vancomycin引起急性腎損傷之案例報告與文獻回顧

Suspect Vancomycin Induced Acute Renal Failure: A Case Report and Literature Review

楊玉鳳(Yu-Fang Yang) ； 蔡慈貞(Tzu-Cheng Tsai)

《臺灣臨床藥學雜誌》 28卷3期 (2020/07) Pp. 247-253

https://doi.org/10.6168/FJCP.202007_28(3).0010

摘要

Vancomycin是治療抗藥性金黃色葡萄球菌（methicillin-resistant Staphylococcus aureus, MRSA）感染的第一線藥物，具腎毒性，可能導致延長住院天數，甚至需要洗腎的情形。本文探討一疑似因vancomycin導致急性腎損傷的案例，此案例為一18歲女生，身高165公分、體重54公斤，患有甲狀腺機能亢進，長期服用methimazole，但控制不佳。此次因間歇性發燒咳嗽有痰一個月、運動後呼吸困難約3星期，呼吸困難情形持續加重就醫，因肺炎併有心臟肥大，懷疑有心包膜積液、心臟衰竭入住兒科加護病房，以vancomycin與ceftriaxone治療肺炎，並投與furosemide，在治療4天後，發生急性腎損傷，血中肌酸酐從0.59上升至5.05mg/dL，vancomycin波谷濃度76.4μg/mL，醫師改以meropenem治療感染，繼續投與furosemide及加強輸液補充以改善腎功能，停藥後腎功能持續改善，於18天後出院，肌酸酐降至0.73mg/dL。依據Naranjoscale評估為5分，屬於「極有可能」。此案例提醒使用vancomycin須注意合併使用藥品評估，腎毒性高風險族群病人須加強監測腎功能與藥品血中濃度並適時評估使用vamcomycin的適當性，如無需要則建議立刻停用；如此方能達最好的治療效果並減少不必要的毒性發生與傷害。

關鍵字

急性腎損傷 ； 腎毒性 ； Vancomycin

並列摘要

Vancomycin is the first line of treatment for methicillin-resistant Staphylococcus aureus (MRSA) infections, which is nephrotoxic and may result in prolonged hospital stays and even dialysis. This article explores a case of suspected acute kidney injury caused by vancomycin. An 18-year-old girl with hyperthyroidism was on long-term treatment with methimazole, but with poor control. Because of intermittent fever, cough, and sputum for 1 month, and dyspnea after exercise for approximately 3 weeks, which continually worsened, she visited the hospital. Due to pneumonia, cardiomegaly, and suspected pericardial effusion, she was admitted to the pediatric intensive care unit. The pneumonia treatment comprised ceftriaxone and vancomycin along with furosemide. After 4 days of treatment, acute kidney injury occurred, and the serum creatinine level increased from 0.59 to 5.05 mg/dL, the trough concentration of vancomycin was 76.4 μg/mL. The antibiotics were replaced with meropenem to treat the infection. Furosemide was injected and fluid supplementation was increased to improve the renal function. The renal function continued to improve after stopping the drug; hence, she was discharged after 18 days, when the serum creatinine level had decreased to 0.73 mg/dL. An adverse drug reaction, with a score of 5 on the Naranjo scale, was considered probable. Thus, vancomycin in combination with other drugs should be prescribed cautiously. Patients with a high risk of nephrotoxicity should be closely monitored for the renal function and serum vancomycin concentration. The appropriateness of the drug use should be evaluated timely, and the drug should be discontinued immediately if not required. Thus, the best treatment can be achieved and unnecessary toxicity and damage can be reduced.

並列關鍵字

Acute Kidney Injury ； Nephrotoxicity ； Vancomycin