Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia

We request clarification regarding the feasibility, reliability, and standardization of the proposed denominator criteria for the Excess Antibiotic Duration and Inappropriately Broad Empiric Antibiotic eCQMs for Community-Acquired Pneumonia.

Specifically, clarification is needed regarding the identification of patients who received a respiratory antibiotic within 48 hours of hospitalization, including whether the timing window is intended to begin at emergency department (ED) arrival, inpatient admission, or another defined encounter start. Variability in how hospitals operationalize ED-to-inpatient transitions within EHR systems may result in inconsistent denominator identification and reduced measure comparability across sites.

Additionally, the proposed denominator criteria include identification of patients with chest imaging performed up to three days prior to the hospital encounter. The availability, structure, and interoperability of chest imaging data from days preceding admission may vary substantially across EHR systems, particularly when imaging is performed in outpatient, urgent care, or external facilities. This variability raises concerns regarding the completeness and reliability of electronically captured imaging data and may lead to unintentional exclusion of otherwise eligible patients.

Without clearer technical specifications and standardized logic for these denominator elements, there is concern that hospitals may experience inconsistent patient identification, increasing implementation burden and potentially undermining the validity and comparability of measure results.

We encourage CMS to provide additional clarification and technical guidance on denominator definitions and data element timing to support consistent, reliable implementation of these eCQMs across diverse hospital settings.

Support with modification: Recommend CMS provide clear technical specifications, allow clinical exceptions for high-acuity populations, and avoid unintended disincentives for appropriate empiric therapy.
This measure brings awareness to ensuring appropriate care and reducing antibiotic overuse, ultimately to ensure providers and providing quality care.  With this being a measure of quality for the provider, it could impact health plans indirectly.  If the provider has a lower quality rating, the reimbursement to them is lower, and that the MIPS performance could create a financial shift as it relates to the cost and quality of care delivered within the health plan. This is a good initiative to support reduction of antibiotic resistance from overuse or overprescribing for viral infections (inappropriate usage).

The American Thoracic Society recommends clinicians only treat empirically for MRSA or P. aeruginosa in adults with CAP if locally validated risk factors for either pathogen are present.  If clinicians are currently covering empirically for MRSA or P. aeruginosa in adults with CAP on the basis of published risk factors but do not have local etiological data, we recommend continuing empiric coverage while obtaining culture data to establish if these pathogens are present to justify continued treatment for these pathogens after the first few days of empiric treatment. This measure description does not currently list what medications would be considered “empiric therapy.” The exclusionary criteria for MRSA and/or Pseudomonas are not inclusive of all strong risk-factors (i.e., Gram-positive cocci in clusters on good-quality sputum Gram stain or Gram-negative bacilli seen on good-quality sputum on Gram stain). Additionally, the 2025 American Thoracic Society Guidelines suggest use of empiric antibiotics for adult inpatients with clinical and imaging evidence of non-severe CAP who have a positive test result for a respiratory virus. Coinfection with respiratory virus is not accounted for in the measure as presented. We would expect to see empiric therapy options included in the technical specs to help address these concerns.  With regards to  exclusionary criteria, “there is sufficient evidence that prior identification of MRSA or P. aeruginosa in the respiratory tract within the prior year predicts a very high risk of these pathogens being identified in patients presenting with CAP, and therefore these were sufficient indications to recommend blood and sputum cultures and empiric therapy for these pathogens in patients with CAP in addition to coverage for standard CAP pathogens, with deescalation at 48 hours if cultures are negative.

Premier supports this measure as it is clinically relevant to hospitals and public health. Premier recommends providing hospitals with sufficient time to build out and test this eCQM measure properly. Premier has concerns about smaller or rural hospitals, as they may lack the appropriate IT resources to build this eCQM.

The Infectious Diseases Society of American (IDSA) is strongly supportive of measure MUC2025-019 addressing agent selection for uncomplicated community acquired pneumonia. Over the past decade, the United States has made major advances in efforts to improve antibiotic use in hospitals as part of efforts to combat the public health crisis of antimicrobial resistance. Nearly all hospitals now have dedicated programs to improve antibiotic use (antibiotic stewardship programs), as required by the Centers for Medicare and Medicaid Services (CMS). The vast majority also now have access to risk adjusted benchmarks for the quantity of their antibiotic use through CDC’s National Healthcare Safety Network Antibiotic Use Option. Such reporting is also now required by CMS.

However, efforts to improve hospital antibiotic use remain challenged by an inability to quickly and easily assess the quality of antibiotic prescribing. Improving the quality of antibiotic use is the ultimate goal of antibiotic stewardship and we need measures that will help us target this goal directly. Studies have consistently shown that assessing the guideline concordance of antibiotic prescribing for common infections consistently leads to better use. 

This measure represents a critical first step into a new era for improving hospital antibiotic use as it targets the single most common reason that antibiotics are prescribed in hospitals. In many hospitals, 50% or more of all antibiotic prescribing is for pneumonia. And because they are electronic, they will allow antibiotic stewardship programs to assess the quality of prescribing without having to conduct labor intensive chart reviews. Data from the endorsement application indicates that use of the manual versions of these measures led to significant improvements in prescribing.

American Thoracic Society (ATS)

Church Street Station

P.O. Box 3421

New York, NY 10008-3421

January 5, 2026

Dear Centers for Medicare & Medicaid Measures Under Consideration (MUC) Staff:

The American Thoracic Society (ATS) formally submits comments below in response to the call for public comments for 2025 MUC Measure #019 Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia.  Comments were sourced from ATS members who are clinical practice guideline authors and quality experts in pneumonia:

Overall impression: Strong face validity but major concerns with measure specifications

Rationale:

1. Exclusion list does not match clinical practice guidelines.  The MRSA and Pseudomonas risk factors are broader than the guideline definition and include illness severity, which could mislead the clinical field into thinking that any patients with severe pneumonia are  appropriate. None of the studies evaluating risk for MRSA or Pseudomonas have found illness severity to be a risk factor for MDR pathogens. This could have the unintended reverse effect of actually increasing inappropriate use of broad-spectrum antibiotics in patients with severe pneumonia. 

1. Exclusion Patients who have had IV or broad spectrum antibiotics in the last 90 days should be excluded in general, and not just those who had IV antibiotics + severe pneumonia in the last 90 days.

1. Diagnosis is not verified by a positive chest image. While the measure includes ordering of a chest image, there will still be 10% of patients that lack pneumonia on chest imaging in this group.

    

2. Consider excluding patients with a positive rapid molecular diagnostic test in addition to positive culture data from lower respiratory secretion samples for MRSA and Pseudomonas.

1. Many patients meeting sepsis criteria will receive their first dose of broad-spectrum antibiotics before the diagnosis of pneumonia is established. Would suggest refining the numerator time window to not include the first dose, but subsequent receipt of broad-spectrum antibiotics after the first does and within 24 or 48 hours.

1. Patients may have a history of MRSA or Pseudomonas in their chart notes based on data from other facilities because presumably the EHR data query will only include microbiology data in the same facility  – it seems like this measure would miss those patients, as well as other risk factors like injection drug use that are not listed in the exclusion criteria.

1. The definition of anti-Pseudomonal and anti-MRSA treatment should be explicit.

1. The focus on MRSA and Pseudomonas ignores the problem of ESBL-producing gram negative bacilli.    

1. Exclusion criteria of immunocompromised patients should also include active chemotherapy.

Sincerely, Katie A. Artis, Committee Chair, Quality Improvement and Implementation, ATS

Vizient supports the agency’s efforts to identify measures to help improve sepsis care. However, the MUC2025-019: Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia measure under consideration, which includes patients with a sepsis diagnosis, may be unnecessary. For example, several of the contemplated measures introduce new requirements which appear to overlap with existing measures that hospitals report, such as the Severe Sepsis and Septic Shock: Management Bundle (SEP‑1). Vizient is concerned that introducing multiple new sepsis‑related measures, especially if existing measures are retained, risks increasing burden without clear evidence regarding which measurement approach, if any, will be most beneficial in the context of patient care.

We are also concerned that this and other sepsis-related measures currently under consideration suggest that CMS is seeking to add several measures to different quality programs, which runs counter to the agency’s aims to reduce the overall number of measures, decrease burden and streamline program requirements. Given the overlap with SEP-1 and the significant burden associated with SEP‑1, we suggest retiring SEP‑1 and replacing it with significantly fewer measures. 

Vizient also notes that the considered sepsis measures would benefit from undergoing additional review, as these measures have not been used in CMS programs or thoroughly vetted or tested by hospitals. Vizient cautions against advancing measures that have not been rigorously evaluated by experts and tested, as such measures may not achieve their desired outcome, create unintended consequences or prove unworkable in real‑world settings. Vizient believes additional analysis and testing would help to better understand the impacts of these measures, including whether similar benefits can be achieved with fewer measures. 

Finally, several of these measures rely on complex algorithms, require precise clinical documentation or depend on data elements that may not be consistently captured across hospitals. For example, MUC2025-019 is an electronic clinical quality measure (eCQMs), which tend to be less burdensome to report than chart-abstracted measures but can still pose challenges for providers. Vizient suggests that additional information be provided related to potential challenges associated with reporting these eCQMs.

SHM asks the measure developers to expand the exclusion criteria for this measure. It should be updated to exclude patients who are considered immunocompromised either due to underlying chronic disease or medication effect, including biologic therapies.

SHM has concern about the interplay between use of broad spectrum antibiotics in the ED setting, where it may be appropriate, and use in the hospitalization setting, where more testing, pathogen identification and narrow antibiotic selection is more commonly possible. SHM recommends considering an exclusion for antibiotics administered in the ED or other emergency setting.

Bon Secours Mercy Health is supportive of the measure to support appropriate use of antibiotic for Community Acquired Pneumonia but would suggest an additional measure exclusion for Infectious Disease consult and management.  Access to pre hospital antibiotics and imaging information can be limited and difficult to capture,  clarification would improve the reliability of the measure.

I'm glad to see a simple and useful metric is being proposed to lessen inappropriate (and potentially worse) antibiotics for community acquired pneumonia (CAP). CAP is one of the most common diagnoses and patients often get suboptimal treatment targeting MRSA or Pseudomonas, although standard options like ceftriaxone/azithromycin better covers organisms causing CAP. 

I think this metric will make sense to clinicians and will actually be found to be wrong in many patients in some hospitals, where the sepsis oriented "vancopime" predominates. 

While this is, inarguably, important to consider, It is unclear if this measure has been tested in rural health settings.  It only referenced hospitals in Michigan with something similar and VA hospitals.  Please evaluate the feasibility in rural settings before considering implementation. Thank you. 

Given the critical role of antibiotic stewardship programs in patient safety and public health, all healthcare institutions across the continuum of care must treat them as a fiduciary responsibility. Furthermore, the CMS Hospital Conditions of Participation regulations require hospitals to maintain policies and procedures for an active, hospital-wide antibiotic stewardship program, demonstrate evidence of its implementation, and ensure improved internal coordination of antibiotic use to limit the development of antibiotic resistance. SHEA supports the development and adoption of antibiotic stewardship measures for CMS Quality Payment Programs and public health reporting to support regulatory compliance requirements and advance patient safety and public health improvement goals. 

After careful review of the proposed MUC2025-019 measure, SHEA has concerns regarding the time and resources required for hospitals to develop the necessary infrastructure to operationalize and implement this measure. Given the exclusion criteria outlined in the measure description, it is unclear how automation could be achieved, which raises the risk of a substantial increase in administrative burden. Specifically, using risk factors for MRSA or Pseudomonas as determinants of appropriateness extends beyond what can be abstracted from EHRs in an automated manner and would necessitate substantial investment of time and resources by hospitals. This outcome would run counter to the overarching goal of reducing administrative complexity through the adoption of modernized measures that are intended to become digital over time.

To support successful implementation, SHEA recommends that CMS engage in close communication and collaboration with EHR vendors to ensure system readiness and the reliability of data validation capabilities necessary for compliance before this measure is adopted. Building this capacity will require adequate time, and hospitals must be afforded sufficient implementation periods to establish new data collection systems effectively.

PQM CBE 4545e: Inappropriately Broad Empiric Antibiotic Selection for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia 

Impact to Patient Outcomes 

• Pneumonia is a leading cause of inpatient antibiotic use and infectious mortality in the US, resulting in significant emergency department visits, hospitalizations, deaths, and costs each year. 
• The measure aims to reduce the use of inappropriately broad empiric antibiotic treatments, which have been associated with higher readmissions, increased ICU transfers, increased antibiotic-associated adverse events, and longer hospital stays. 
• This measure can help hospitals understand their antibiotic prescribing practices and ensure that CAP patients receive guideline-concordant therapy, thereby reducing the risk of adverse events from antibiotics and the development of antibiotic resistance. 
• Initiatives that support guideline concordant antibiotic utilization not only improve outcomes but also can help reduce healthcare costs. 

Alignment with other measures 

• The measure complements other quality efforts, such as sepsis-related measures, by focusing on the correct empiric therapy for CAP. 
• The measure aligns with and reinforces the recommendations from national organizations like the Centers for Disease Prevention and Control (CDC), The Joint Commission, and Centers for Medicare and Medicaid Services, which emphasize the importance of antibiotic stewardship programs.  

Supporting this quality measure is a step towards enhancing the overall quality of care for patients with CAP, promoting responsible antibiotic use, improving patient outcomes and reducing healthcare costs. 

 Organization

Advocate Health

Relevant concern for overuse of empiric antibiotic therapy in that higher rates of resistance are occurring.  Providers are held accountable starting antibiotics before sensitivity tests are completed.  It does become challenging with other quality measures like treatment of sepsis exist pushing faster timelines like time to treat within bundles including antibiotic use. 

This measure appears reasonable and aligns with ongoing efforts in Kansas to reduce HAI/AR to improve care quality and patient safety.