OBJECTIVE:To explore the role of clinical pharmacists providing pharmaceutical care for hemodialysis patients complicated with subacute infective endocarditis(IE). METHODS:Clinical pharmacists participated in the anti-infection treatment for a hemodialysis patients complicated with subacute IE,according to the antimicrobial spectrum,laboratory and imaging find-ings,and patient’s condition changes,assisted physician to optimize the regimen,clinical pharmacists suggested to give imipenem cilastatin sodium after hemodialysis,adjust the initial dose of teicoplanin and give 1 g vancomycin firstly,and maintained 0.5 g af-ter hemodialysis,then adjust its dose based on blood plasma concentration;during treatment,clinical pharmacists closely observed the treatment effect and adverse reactions,providing blood plasma concentration monitoring,medication reminding and medication education. RESULTS:Physicians adopted parts of suggestions of clinical pharmacists,no fever was found,hemogram returned to normal,no abnormal echocardiography,and patient discharged. CONCLUSIONS:Clinical pharmacists guarantee the safety and ef-ficacy of drug use by adopting dose of anti-infection drugs,evaluating efficacy,monitoring adverse reactions and vancomycin plas-ma concentration,and assisting physicians to optimize treatment regimen.

Objective:To improve the quality and efficiency of pharmaceutical care of clinical pharmacists by standardizing phar-maceutical care process using tracking table design for clinical drug therapy. Methods: The experience and skills of pharmaceutical care performed by clinical pharmacists in endocrinology department were summarized and the tracking table for clinical drug therapy was designed, which could provide information for patients clearly and concisely, and make the process of pharmaceutical care more system-atical. Results:After using the tracking table, clinical pharmacists improved work efficiency significantly. In addition, the average hospitalization, average hospitalization expenses and drug proportion significantly reduced resulting in higher satisfaction of patients. Conclusion:The standardized pharmaceutical care process performed by clinical pharmacists in endocrinology department makes phar-maceutical care more specific, comprehensive and convenient.

OBJECTIVE:To strengthen the supervision of clinical antibiotics use through establishing electronic consultation system. METHODS:Based on hospital information system(HIS)and antibiotic management system,consultation system for anti-biotics of special use(ASU)was established,and the effects of the system after used(Jan. 2014)were also evaluated. RESULTS:Real-time consultation of ASU medical orders and related consultation results inquiry and statistics could be achieved through de-signing ASU consultation application form,establishing consultation experts and confirming their working content,adding statistics function,etc. The consultation have been finished 8275 times from 2014 to 2015. The inspection rate for pathogenic microbes in ASU patients rose from 78.68% in 2013 to 83.90% in 2015. CONCLUSIONS:The establishment and application of ASU consulta-tion system can improve consultation efficiency and quality,so as to promote rational use of antibiotics in the clinic.

Objective To investigate the effect of clinical pharmacists in the analgesic therapysoas to improve the rational use of analgesic drugs .Methods Clinical pharmacists participated in the formulation of drug therapy plan for the patient of cancer pain with renal insufficiency in respects of drug selection ,dosage and adverse reaction monitoring .Results Physicians accepted suggestions from clinical pharmacists .The first day ,the morphine hydrochloride tablets were used for rapid titration . The next day doxycodone were used ,adding the morphine hydrochloride tablets when required .After the pain was controlled stability ,the transdermal fentanyl was used to alleviate the damage of kidney .Conclusion The clinical pharmacist could assist clinicians to adjust the therapeutic regimen of the cancer patients with severe pain and improve the level of clinical drug treat-ment .

Objective To analyse the distribution of main pathogens and drug resistance in a tertiary hospital during 2014 ,and to provide the reference for the clinical rational use of antimicrobial agents .Methods Conventional methods were used for bacterial culture ,VITEK-2 automatic detection system of French BioMerieux company was used for bacteria identifica-tion ,and bacterial resistance analysis ,and WHO NET 5 .5 software was used for data analysis .Results Gram negative bacte-ria accounted for 78 .09% ;Gram positive bacteria accounted for 21 .91% .K lebsiella pneumoniae detection rate was the high-est ,that is 16 .07% ,followed by EscherichiaColi (12 .75% ) ,Bauman Acinetobacter (12 .69% ) and Pseudomonas aeruginosa (10 .91% ) .The resistant rate of methicillin resistant Staphylococcus aureus(MRSA)was 42 .8% (101) ,and the resistant rate of methicillin resistant coagulase negative staphylococci (MRCNS) was 75 .62% (152) .Resistant rates of Staphylococcus au-reus ,both coagulase negative staphylococcus and enterococcus faecalis to vancomycin and linezolid were zero .Resistant rates of enterococcus faecium to vancomycin and linezolid were 5 .5% and zero respectively .Pathogens were detected mainly in emer-gency department ,and the main pathogens were widely distributed .Conclusion Conducting monitoring of bacterial drug re-sistance and grasping the change trend of drug resistance have important significance to guide clinical rational drug use .

OBJECTIVE：To investi gate the role of clinical pharmacists in the treatment of delayed excretion of acute renal failure （ARF） with epileptic seizure caused by HD-MTX in a patient ，and to provide reference for rational drug use and pharmaceutical care in such type of patients. METHODS ：A patient with diffuse large B-cell lymphoma was given HD-MTX for chemotherapy，and ARF caused by delayed methotrexate excretion occurred on the second day after methotrexate administration. Clinical physicians adjusted the rescue dose and frequency of calcium folinate but the effect was poor. Clinical pharmacists analyzed the causes of delayed methotrexate excretion by reviewing literature and combining with the patient ’s condition. It was suggested to monitor the blood concentration of methotrexate ，strengthen alkalization and hydration ，increase the volume of intravenous sodium bicarbonate from 125 mL to 250 mL，take Sodium bicarbonate tablets orally ，and monitor the pH value of urine （pH value of urine maintained above 7）. In addition ，the pharmacist told the patient to drink water as much as possible to ensure the daily urine output reached 3 000 to 4 000 mL. The blood concentration of methotrexate was 16.14 μmol/L 44 h after administration ，which proved to be excretion delay. The patient had epileptic seizure on the 13th day after methotrexate medication. The physician gave sodium valproate 0.8 g intravenously to control epilepsy. The clinical pharmacist conducted pharmaceutical care for the patient ，and found that the compliance of the patient taking Sodium bicarbonate tablets and Sodium valproate tablets orally was not good ，so medication education and pharmaceutical care were conducted ，then the patient accepted and took the drugs on time. RESULTS ： The physician adopted the suggestions of the pharmacist to monitor the blood concentration of methotrexate and performed symptomatic treatment. The urine volume of the patient increased ，the edema was reduced ，serum creatinine gradually returned to normal，and renal function recovered gradually ；the symptoms of epilepsy was controlled. CONCLUSIONS ：In the treatment process of ARF complicated with epileptic seizure caused by excretion delay of HD-MTX ，the clinical pharmacist assisted physician to improve the treatment plan and conducted pharmaceutical care and medication education for the patient ，therefore ensure the safe and rational use of drugs .