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*Three questions and three answers for a case of medication reaction only for medical professionals.
Urinary tract infection is a common clinical urinary system disease.
It is caused by the growth and reproduction of viruses, bacteria, mycoplasma, and chlamydia in the patient's urinary tract.
The incidence of infection is higher in women [1]
.
The choice of antibacterial drugs to treat urinary tract infections has always been a problem for clinicians and pharmacists
.
Especially in primary medical institutions, some patients with a history of high-risk diseases may choose to come to a community clinic for treatment because of a “minor disease” such as urinary tract infection.
For these patients, they need to be extra careful in their choice of medication
.
Let me introduce a case to everyone: Case introduction The case introduces the patient, female, 58 years old, who came to the community clinic for medical treatment due to urinary tract infection
.
Complaints of frequent urination, urgency, dysuria, no tenderness in the kidney area, dark yellow urine
.
He has multiple ulcers in the mouth, and he has diabetes in the past.
He was treated with oral metformin and insulin injections
.
He has a history of coronary heart disease and has undergone coronary stenting
.
He complained of lacunar cerebral infarction and was treated with medication
.
The examination results of urine occult blood (+), urine white blood cells (++), urine sugar (++); WBC1.
3×109, RBC 3.
9×1012, PLT298×109
.
Past ECG showed old myocardial ischemia
.
Prescription normal saline 250ml + clindamycin 0.
9g, normal saline 250ml + levofloxacin 0.
3g, intravenous infusion
.
Suddenly, when clindamycin (30 drops per minute, 0.
6 gauge needle) was suspended for less than 20 minutes, the patient developed stomach upset
.
The doctor hurriedly gave acupoint massage on the stomach.
The patient's symptoms improved, but within 5 minutes of the improvement, he fainted, had slight muscle tremors, and stared at the eyes
.
So he was given 1mg of epinephrine hydrochloride injection into the deltoid muscle immediately, and the patient immediately became conscious, with a blood pressure of 120/50mmHg (the patient’s family complained of the patient’s previous blood pressure of 135/90-100mmHg), a heart rate of 60 beats/min, and arrhythmia
.
Five minutes later, 0.
5 mg of epinephrine was injected into the deltoid muscle again, and 5 mg of dexamethasone was put into the pot
.
Symptoms improved a bit, promptly called 120 to be sent to a higher-level hospital.
On the way, the patient complained of pain in the precordial area and was given 0.
5 mg of nitroglycerin sublingually
.
After arriving at the higher-level hospital, the ECG showed acute ischemic changes, and he was sent to the cardiology department for treatment.
After the cardiology night shift doctor checked the cause of epigastric pain and acute myocardial ischemia for coronary heart disease, he was hospitalized for observation
.
1.
In this case, what mistakes were made in the medication? ■ Mistake 1 Inappropriate choice of medication Urinary tract infections are mostly Escherichia coli infections, while clindamycin mainly targets Gram-positive bacteria
.
In addition, the National Food and Drug Administration (NMPA) warned in 2009 that clindamycin injections may cause serious adverse reactions such as renal damage and hematuria [2]
.
Therefore, clindamycin should not be the first choice for empirical treatment of urinary tract infections, but levofloxacin empirical medication should be selected.
Clindamycin combined with levofloxacin antibacterial therapy is not necessary
.
■ Mistake 2 Improper drug usage Clindamycin is a time-dependent antibacterial drug.
Before intravenous infusion, the drug should be diluted with 0.
9% sodium chloride injection or 5% glucose injection, and 600mg of the drug should be added to 100ml～200ml for infusion Medium, the drip rate should be slow, at least 30-50 minutes of infusion [3]
.
One time use 900mg, and the patient is an elderly person, the single dose of the drug is too large; Levofloxacin is a concentration-dependent antibacterial drug, generally should be 500mg once a day [4]
.
The dosage of the medicine in this case is not standardized
.
■Error 3 Improper first aid medication In general, patients with high blood pressure or heart disease should disable epinephrine
.
However, when anaphylactic shock occurs in patients with hypertension or heart disease, the whole body tissues and organs are in a state of shock due to blood pressure drop or undetectable, and the use of epinephrine is not contraindicated in this emergency
.
However, it should be noted that the first dose should not be too large, generally 0.
5mg [5], and then repeat the dose as needed.
At the same time, the changes in the condition should be closely observed to prevent high blood pressure and rapid heart rate
.
In this case, an extremely large amount of 1 mg was used for one administration, which is too large
.
Two or three previous history of high-risk diseases, can the community clinic accept such patients? Since the record of the course of this case is not very detailed, the only analysis of the existing data is as follows: There is nothing wrong with the case in the community clinic
.
However, according to the patient's history of high-risk diseases such as diabetes, coronary heart disease (four stent operations), and cerebral infarction, when treating urinary tract infections, a comprehensive auxiliary examination is required, and the appropriate treatment plan can be determined by combining the previous medical history.
Community clinics cannot be completed, and it is safer to be transferred to a higher-level hospital for treatment in time
.
Infusion therapy is a treatment method with medical risks.
Community clinics do not have first aid facilities and technology.
Once a patient has an infusion reaction, it is difficult to receive effective treatment
.
The case was indeed lucky and survived the transfer
.
In addition, in accordance with the "layered medical" design of the national medical reform policy, the responsibility of community doctors is mainly to provide residents with basic national public health services, including the establishment of residents’ health files, health education, vaccination, infectious disease prevention, child health care, and pregnant women.
health care, elder care, chronic disease management, management of severe mental illness
.
From the perspective of the scope of services, there is no need to carry out risky infusion therapy
.
After three patients respond to medication, is the follow-up treatment correct? ■Clindamycin adverse reactions include: arrhythmia (ventricular fibrillation secondary to prolonged QT interval, torsade de pointes ventricular tachycardia, atrioventricular block) and blood pressure drop
.
Basic-level doctors are really helpless in judging such conditions.
Even if they go to a higher-level hospital, they must modify the diagnosis and treatment on the basis of perfecting the relevant examinations
.
Judging from the follow-up situation, the patient's gastric discomfort is actually an early manifestation of myocardial ischemic angina
.
Therefore, first stop intravenous infusion of clindamycin instead of performing gastric acupoint massage
.
■Syncope, that is, a brief loss of consciousness
.
It is caused by a sudden decrease in the blood supply to the brain
.
Before the person faints, there may be sudden dizziness, weakness, feeling unwell, and sweating.
However, there may be no aura and sudden fainting.
The patient may have binocular staring, convulsions and other phenomena
.
The general treatment methods are as follows: immediately lay the patient flat, loosen the tights, and raise the lower limbs with head down and feet high to facilitate unblocked breathing and increase the blood supply to the brain.
At the same time, check the patient’s breathing, blood pressure and pulse.
.
Keeping the patient in a well-ventilated place can provide physical stimulation or verbal stimulation to the patient
.
Oxygen can be given when necessary to help the patient regain consciousness .
This patient has a history of diabetes and should be checked whether syncope is related to hypoglycemia
.
If it is, drink sugar water in moderation
.
The community clinic in this case did a good job immediately and saved the patient’s life
.
After reading the analysis of this case, do you think it has gained something? Please leave a message in the comment area for discussion~ References: [1] Xu Jiquan, Liang Linhui.
Types of urinary tract infections, pathogens and treatment research progress[J].
Journal of Aerospace Medicine, 2021, 32 (09): 1101-1102.
[2] Notice on revising the instructions for clindamycin injections, State Food and Drug Administration Note [2009] No.
381, 2009.
07.
30.
[3] Notice on strengthening the management of clinical use of clindamycin injections, Health Office Medical Policy Issue [2009] No.
107, 2009.
06.
26.
[4] Tang Jie et al.
, the efficacy of levofloxacin 500 mg once a day in the treatment of bacterial lower respiratory tract infections.
"Journal of Clinical Pulmonology" 2006 Issue 5 [5] Li Xiaotong and others "Severe Recommendations of the "Guidelines for First Aid for Allergic Reactions"[J].
Adverse Drug Reactions Magazine, 2019, 21(2): 85-91.
Urinary tract infection is a common clinical urinary system disease.
It is caused by the growth and reproduction of viruses, bacteria, mycoplasma, and chlamydia in the patient's urinary tract.
The incidence of infection is higher in women [1]
.
The choice of antibacterial drugs to treat urinary tract infections has always been a problem for clinicians and pharmacists
.
Especially in primary medical institutions, some patients with a history of high-risk diseases may choose to come to a community clinic for treatment because of a “minor disease” such as urinary tract infection.
For these patients, they need to be extra careful in their choice of medication
.
Let me introduce a case to everyone: Case introduction The case introduces the patient, female, 58 years old, who came to the community clinic for medical treatment due to urinary tract infection
.
Complaints of frequent urination, urgency, dysuria, no tenderness in the kidney area, dark yellow urine
.
He has multiple ulcers in the mouth, and he has diabetes in the past.
He was treated with oral metformin and insulin injections
.
He has a history of coronary heart disease and has undergone coronary stenting
.
He complained of lacunar cerebral infarction and was treated with medication
.
The examination results of urine occult blood (+), urine white blood cells (++), urine sugar (++); WBC1.
3×109, RBC 3.
9×1012, PLT298×109
.
Past ECG showed old myocardial ischemia
.
Prescription normal saline 250ml + clindamycin 0.
9g, normal saline 250ml + levofloxacin 0.
3g, intravenous infusion
.
Suddenly, when clindamycin (30 drops per minute, 0.
6 gauge needle) was suspended for less than 20 minutes, the patient developed stomach upset
.
The doctor hurriedly gave acupoint massage on the stomach.
The patient's symptoms improved, but within 5 minutes of the improvement, he fainted, had slight muscle tremors, and stared at the eyes
.
So he was given 1mg of epinephrine hydrochloride injection into the deltoid muscle immediately, and the patient immediately became conscious, with a blood pressure of 120/50mmHg (the patient’s family complained of the patient’s previous blood pressure of 135/90-100mmHg), a heart rate of 60 beats/min, and arrhythmia
.
Five minutes later, 0.
5 mg of epinephrine was injected into the deltoid muscle again, and 5 mg of dexamethasone was put into the pot
.
Symptoms improved a bit, promptly called 120 to be sent to a higher-level hospital.
On the way, the patient complained of pain in the precordial area and was given 0.
5 mg of nitroglycerin sublingually
.
After arriving at the higher-level hospital, the ECG showed acute ischemic changes, and he was sent to the cardiology department for treatment.
After the cardiology night shift doctor checked the cause of epigastric pain and acute myocardial ischemia for coronary heart disease, he was hospitalized for observation
.
1.
In this case, what mistakes were made in the medication? ■ Mistake 1 Inappropriate choice of medication Urinary tract infections are mostly Escherichia coli infections, while clindamycin mainly targets Gram-positive bacteria
.
In addition, the National Food and Drug Administration (NMPA) warned in 2009 that clindamycin injections may cause serious adverse reactions such as renal damage and hematuria [2]
.
Therefore, clindamycin should not be the first choice for empirical treatment of urinary tract infections, but levofloxacin empirical medication should be selected.
Clindamycin combined with levofloxacin antibacterial therapy is not necessary
.
■ Mistake 2 Improper drug usage Clindamycin is a time-dependent antibacterial drug.
Before intravenous infusion, the drug should be diluted with 0.
9% sodium chloride injection or 5% glucose injection, and 600mg of the drug should be added to 100ml～200ml for infusion Medium, the drip rate should be slow, at least 30-50 minutes of infusion [3]
.
One time use 900mg, and the patient is an elderly person, the single dose of the drug is too large; Levofloxacin is a concentration-dependent antibacterial drug, generally should be 500mg once a day [4]
.
The dosage of the medicine in this case is not standardized
.
■Error 3 Improper first aid medication In general, patients with high blood pressure or heart disease should disable epinephrine
.
However, when anaphylactic shock occurs in patients with hypertension or heart disease, the whole body tissues and organs are in a state of shock due to blood pressure drop or undetectable, and the use of epinephrine is not contraindicated in this emergency
.
However, it should be noted that the first dose should not be too large, generally 0.
5mg [5], and then repeat the dose as needed.
At the same time, the changes in the condition should be closely observed to prevent high blood pressure and rapid heart rate
.
In this case, an extremely large amount of 1 mg was used for one administration, which is too large
.
Two or three previous history of high-risk diseases, can the community clinic accept such patients? Since the record of the course of this case is not very detailed, the only analysis of the existing data is as follows: There is nothing wrong with the case in the community clinic
.
However, according to the patient's history of high-risk diseases such as diabetes, coronary heart disease (four stent operations), and cerebral infarction, when treating urinary tract infections, a comprehensive auxiliary examination is required, and the appropriate treatment plan can be determined by combining the previous medical history.
Community clinics cannot be completed, and it is safer to be transferred to a higher-level hospital for treatment in time
.
Infusion therapy is a treatment method with medical risks.
Community clinics do not have first aid facilities and technology.
Once a patient has an infusion reaction, it is difficult to receive effective treatment
.
The case was indeed lucky and survived the transfer
.
In addition, in accordance with the "layered medical" design of the national medical reform policy, the responsibility of community doctors is mainly to provide residents with basic national public health services, including the establishment of residents’ health files, health education, vaccination, infectious disease prevention, child health care, and pregnant women.
health care, elder care, chronic disease management, management of severe mental illness
.
From the perspective of the scope of services, there is no need to carry out risky infusion therapy
.
After three patients respond to medication, is the follow-up treatment correct? ■Clindamycin adverse reactions include: arrhythmia (ventricular fibrillation secondary to prolonged QT interval, torsade de pointes ventricular tachycardia, atrioventricular block) and blood pressure drop
.
Basic-level doctors are really helpless in judging such conditions.
Even if they go to a higher-level hospital, they must modify the diagnosis and treatment on the basis of perfecting the relevant examinations
.
Judging from the follow-up situation, the patient's gastric discomfort is actually an early manifestation of myocardial ischemic angina
.
Therefore, first stop intravenous infusion of clindamycin instead of performing gastric acupoint massage
.
■Syncope, that is, a brief loss of consciousness
.
It is caused by a sudden decrease in the blood supply to the brain
.
Before the person faints, there may be sudden dizziness, weakness, feeling unwell, and sweating.
However, there may be no aura and sudden fainting.
The patient may have binocular staring, convulsions and other phenomena
.
The general treatment methods are as follows: immediately lay the patient flat, loosen the tights, and raise the lower limbs with head down and feet high to facilitate unblocked breathing and increase the blood supply to the brain.
At the same time, check the patient’s breathing, blood pressure and pulse.
.
Keeping the patient in a well-ventilated place can provide physical stimulation or verbal stimulation to the patient
.
Oxygen can be given when necessary to help the patient regain consciousness .
This patient has a history of diabetes and should be checked whether syncope is related to hypoglycemia
.
If it is, drink sugar water in moderation
.
The community clinic in this case did a good job immediately and saved the patient’s life
.
After reading the analysis of this case, do you think it has gained something? Please leave a message in the comment area for discussion~ References: [1] Xu Jiquan, Liang Linhui.
Types of urinary tract infections, pathogens and treatment research progress[J].
Journal of Aerospace Medicine, 2021, 32 (09): 1101-1102.
[2] Notice on revising the instructions for clindamycin injections, State Food and Drug Administration Note [2009] No.
381, 2009.
07.
30.
[3] Notice on strengthening the management of clinical use of clindamycin injections, Health Office Medical Policy Issue [2009] No.
107, 2009.
06.
26.
[4] Tang Jie et al.
, the efficacy of levofloxacin 500 mg once a day in the treatment of bacterial lower respiratory tract infections.
"Journal of Clinical Pulmonology" 2006 Issue 5 [5] Li Xiaotong and others "Severe Recommendations of the "Guidelines for First Aid for Allergic Reactions"[J].
Adverse Drug Reactions Magazine, 2019, 21(2): 85-91.
