Use Case Scenarios

Clinical and Public Health Scenario Use Cases

Patient A, a 65 y/o male, originally seen at a critical access hospital is transferred to the regional health center and admitted for a suspected case of infectious pneumonia and low oxygen levels. The patient also has cirrhosis of the liver.  A respiratory pathogen panel is ordered by the admitting physician to confirm the pneumonia is due to a bacterial infection.   The lab test is ordered in the EHR.  A n/p swab specimen is collected and sent to the micro lab for testing. 

The test performed in the lab is a PCR-based panel.  Within 4 hours, the laboratory reports the positive identification of a Klebsiella pneumoniae infection.  A reflex susceptibility test is ordered by the laboratory.  In the meantime, the physician orders the preferred antibiotic in line with empirical evidence provided by the institutional antibiogram and in accordance with the antimicrobial stewardship protocols of the hospital.

Susceptibility results indicate that the Klebsiella pneumoniae is an extended spectrum beta lactamase (ESBL) producing organism that is resistant to the initially prescribed therapy.  It is only susceptible to antibiotics in the carbapenem family, but many of the readily available carbapenems impact the liver and will be difficult for the patient to tolerate. The physician must identify a suitable alternative.  In previous years, this would have been a very challenging scenario and involved consultations with the infectious disease attending physician and the pharmacist on duty.  However, the hospital has adopted the integrated terminology standards that link lab testing, organisms and medicinal products.  As a result, the physician is able to query the EHR/CDSS for alternative carbapenem drugs on the hospital formulary. The physician is able to identify a suitable cabapenem in the hospital formulary that will control the infection and should be tolerated well by the patient.  The medications are ordered.   The physician requests that past hepatic profile test results from the critical access hospital be imported into the EHR, and the physician orders a series of HPT’s to monitor the patient’s liver function compared to baseline function during carbapenem therapy. The patient recovers after 5 days of therapy and is subsequently discharged.

During the course of laboratory testing, the organism identified along with its susceptibility profile is recorded.  The data are immediately incorporated into the hospital’s antibiogram calculations and will be incorporated into the next publication by the antimicrobial stewardship team.  The organism and susceptibility data are further reported to the state department of epidemiology via HL7 message including S/I/R and MIC data along with testing methods for organism identification and susceptibility test results as ESBL-producing Klebsiella pneumoniae are a reportable condition due to the rise in antimicrobial resistance in this species.   Furthermore, isolates of the organism are sequenced and profiled for known or suspected genes associated with antimicrobial resistance as part of a broader ASM discovery and intervention program.

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