中间链球菌偶尔会导致可能危及生命的脑脓肿,需要及时的抗生素和神经外科治疗。来源通常是牙齿,它可能会扩散到眼睛或脑实质。我们报告了一个34岁的男性,有根尖周炎的迹象,眼内炎,和由中间链球菌引起的多发性脑脓肿。由于亚治疗浓度,美罗培南和万古霉素的初始治疗不成功,尽管推荐剂量。只有将美罗培南的剂量增加到16g/天,万古霉素的剂量增加到1.5g×4后,才能达到足够的浓度。患者表现出高肌酐清除率,与肾脏清除率增加一致。尽管碘海醇和胱抑素C清除率正常。血浆游离万古霉素清除率跟随肌酐清除率。一天剂量的甲氧苄啶-磺胺甲恶唑导致血清肌酐增加,肌酐和尿素清除率均降低。这些结果表明,药物的肾小管分泌增加是抗生素治疗欠佳的原因。病人最终康复了,但他的左眼需要摘除.我们的案例表明,增强的肾脏清除率可能会危害严重细菌感染的治疗,并且在这种情况下需要高剂量的抗生素才能达到治疗浓度。肌酐肾小管转运体的调节机制,尿素,万古霉素,并对美罗培南在危重患者中的应用进行了讨论。
Streptococcus intermedius occasionally causes brain abscesses that can be life-threatening, requiring prompt antibiotic and neurosurgical treatment. The source is often dental, and it may spread to the eye or the brain parenchyma. We report the
case of a 34-year-old man with signs of apical periodontitis, endophthalmitis, and multiple brain abscesses caused by Streptococcus intermedius. Initial treatment with meropenem and vancomycin was unsuccessful due to subtherapeutic concentrations, despite recommended dosages. Adequate concentrations could be reached only after increasing the dose of meropenem to 16 g/day and vancomycin to 1.5 g × 4. The patient exhibited high creatinine clearance consistent with augmented renal clearance, although iohexol and cystatin C clearances were normal. Plasma free vancomycin clearance followed that of creatinine. A one-day dose of trimethoprim-sulfamethoxazole led to an increase in serum creatinine and a decrease in both creatinine and urea clearances. These results indicate that increased tubular secretion of the drugs was the cause of suboptimal antibiotic treatment. The patient eventually recovered, but his left eye needed enucleation. Our
case illustrates that augmented renal clearance can jeopardize the treatment of serious bacterial infections and that high doses of antibiotics are needed to achieve therapeutic concentrations in such cases. The mechanisms for regulation of kidney tubular transporters of creatinine, urea, vancomycin, and meropenem in critically ill patients are discussed.