Excess Antibiotic Duration for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia

 This measure appears reasonable and aligns with ongoing efforts in Kansas to promote antibiotic stewardship and the principle that, when clinically appropriate, shorter durations of therapy improve care quality and patient safety.

Antibiotic use and resistance is a pertinent topic for pneumonia patients.  Health care providers need to be sensitive and aware of best practice.  Since it is an electronic measure. the burden to providers is limited.  Endorsing this measure seems approrate and high value. 

PQM CBE 4540e: Excess Antibiotic Duration for Adult Hospitalized Patients with Uncomplicated Community-Acquired Pneumonia 

 The quality measure for reducing excess antibiotic duration in patients hospitalized with uncomplicated community-acquired pneumonia (CAP) is crucial for several reasons.  

Impact to Patient Outcomes: 

• Pneumonia is a leading cause of inpatient antibiotic use and infectious mortality in the US, resulting in significant healthcare costs and adverse outcomes. 
• Studies have shown that shorter antibiotic durations are as clinically effective as longer durations but are associated with fewer adverse events and a reduced risk of developing antibiotic-resistant infections. 
• The testing of this measure across three large health systems demonstrated success in improving appropriate antibiotic duration while also decreasing adverse events. 
• By adopting this guideline-based measure, organizations can enhance patient care, reduce antibiotic-associated harm such as Clostridioides difficile infection, and contribute to the broader effort of combating antibiotic resistance. 

Feasibility of Measure Data Collection 

• All of the data elements collected are part of routine healthcare system processes for care delivery and billing. 
• Requirements of the proposed measure does not add any additional burdens for a healthcare system.  

Alignment with Other Quality Initiatives 

• This measure aligns with other quality efforts, such as readmissions, mortality and length of stay. 
• The measure will complement existing antibiotic use monitoring systems like the NHSN AU module. 

Overall, implementing this quality measure is both impactful, aligned and feasible and can lead to significant improvements in patient outcomes and public health by promoting responsible antibiotic use and reducing the burden of antibiotic resistance. 

Organization

Advocate Health

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 MUC2025-016 measure, SHEA has significant concerns regarding the time and resources required for hospitals to develop the infrastructure necessary for its operationalization and implementation. The exclusion criteria outlined in the measure description raise questions about the feasibility of automation. This approach risks creating a considerable administrative burden, which is contrary to the overarching goal of reducing such burdens through the adoption of modernized measures intended to become digital.

To facilitate successful implementation, SHEA recommends that CMS engage in close collaboration with EHR vendors to ensure system readiness and the reliability of data validation capabilities required for compliance before this measure is adapted. Building this capacity will take time, and hospitals must be provided with sufficient implementation periods to establish new data collection systems effectively.

Hospitals are already reporting AU and AR to NHSN, and it is required for many states.  I do not understand the benefit of this measure in addition to reporting that is already occurring.  It seems duplicative and costly given that work is already underway in this space more broadly than just community-acquired pneumonia.  Thank you. 

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.   Additionally, the measure would benefit from clarification surrounding how pre hospitalization antibiotic and imaging are captured.   

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.

The American Hospital Association appreciates the opportunity to review this measure on excess antibiotic duration. The measure’s rationale cites CDC’s Antibiotic Stewardship efforts, in which AHA and its American Organization for Nursing Leadership have long been engaged as partners. We are particularly interested in how CDC and CMS plan to update the measure’s specifications in light of recently changed clinical guidelines; that is, while CDC updated its guidelines in July 2025 to recommend less than 5 days duration with a minimum of three days (rather than at least 5), the measure retains the 5-day cut-off “to reflect current practice.” The Preliminary Analysis suggests that the Agencies could shift the defined duration of antibiotics in this measure in the future as clinicians get up-to-speed with the new guideline. Before the measure is proposed for inclusion in CMS quality programs, we recommend that the agency provide a forward-looking strategy to ensure that this measure is in line with evidence-based clinical practice. Similarly, we also recommend that CMS provide a specific plan to monitor the use of the measure for unintended consequences, such as under-treatment on community-acquired pneumonia.

In addition, we hope that the measure steward can provide information on whether the conditions by which the measure was endorsed by the CBE have been met. First, we are interested in how the measure performs as an eCQM. Testing of the measure was conducted via chart review, and the Preliminary Analysis raised feasibility concerns for implementation of this measure in Critical Access Hospitals and smaller hospitals with limited IT infrastructure. In addition, we are curious as to whether additional investigation of exclusions and additional validity testing has produced useful information to guide implementation of this measure. 

Vizient supports the agency’s efforts to identify measures to help improve sepsis care. However, the MUC2025-016: Excess Antibiotic Duration 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 proposed sepsis measures rely on complex algorithms, require precise clinical documentation or depend on data elements that may not be consistently captured across hospitals. For example, MUC2025-016 is an electronic clinical quality measure (eCQM), which tends 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.

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 #016 Excess Antibiotic Duration 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.  The exclusion of “time to clinical stability > 5 days" should be clearly defined and apply the ATS/IDSA guideline definition.   (afebrile (no fever), heart rate < 100 bpm, respiratory rate < 24/min, SpO2 ≥ 90% (or PaO2 ≥ 60 mmHg on room air), systolic blood pressure ≥ 90 mmHg, and normal mental status, often alongside the ability to eat and improved symptoms, signaling readiness for antibiotic discontinuation or IV-to-Oral switch)

    

2. Time to clinical stability requires daily measurements of clinical stability including oxygenation, which may be difficult for some EHRs. How clinical stability will be defined and how often it will be assessed and measured should be clearly specified to determine patients for whom this measure applies up front, not listed as a line item in the exclusion criteria

    

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

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

    

2. Exclusion of any patients with greater than 14-day total antibiotic duration on the assumption that these “likely not for uncomplicated CAP" seems categorical and could potentially miss the exact patients that the measure is attempting to identify.

1. Restriction of denominator only to non-ICU is not consistent with clinical practice guidelines (which categorize patients based on non-severe inpatient and severe inpatients). Excessive duration of antimicrobials is also an issue for ICU-admitted patients.​

1. If the clinical data are incomplete, many complicated patients could get too short of a course and/or not be switched to potentially more appropriate antibiotics because of this quality measure.

Sincerely, Committee Chair, Quality Improvement and Implementation, ATS

The Infectious Diseases Society of American (IDSA) is strongly supportive of measure MUC2025-016 addressing duration of antibiotic therapy 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.

We urge CMS to consider the potential unintended consequence of increasing pneumonia readmissions when antibiotic courses are shortened without adequate clinical safeguards, as well as stratifying risk factors based on inpatient history and inpatient status. 

Please supply standardized EMR logic packages and adopt improvement trajectories rather than punitive thresholds during initial years. 

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.

requesting clarification and concern regarding the feasibility and reliability of patient identification (denominator) criteria for the proposed measures, including:​

• Identification of patients who received a respiratory antibiotic within 48 hours of hospitalization, specifically whether the timing clock begins at ED arrival or inpatient admission; and​

• Identification of patients who had chest imaging 3 days prior to hospital encounter, noting that the availability and consistency of chest imaging data from days prior to admission may vary across EHR systems​

   

Support with modification: Recommend continued use with hospital quality programs.
Recommend clarifying attribution across care transitions, ensure EHR vendor consistency to avoid penalizing for hospital documentation variability, and consider risk stratification for medically complex populations.
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.  

Per review of American Thoracic Society guidelines for the treatment of hospitalized patients with uncomplicated CAP, most patients will achieve clinical stability within the first 48-72 hours of treatment, such that a total therapy duration of 5 days will be appropriate for most patients.   It is reasonable to monitor for patients who receive 7 or more days of prescribed antibiotic therapy for this specific use. However, while the 2025 American Thoracic Society guidelines do recommend <5 days of antibiotics for adult inpatients with non-severe CAP, it is a “conditional recommendation” with “low-quality” evidence and “requires individualization” by patient.  It may also be very difficult to influence and monitor medications dispensed both in hospital and outpatient to total the day supply.  Overall, clinical measures require individualization and that this is an important factor when treating these patients.  The fact that a majority of patients show clinical improvement over 48-72 hours seems reasonable to design the measure to look at members who have had 7 or more days of therapy.

Recommend that CMS determine a reasonable percentage of patients needing 7 or more days of therapy, and this wouldn’t be known unless this measure is approved.

We would need to put effort toward how best to monitor length of antibiotic therapy across inpatient and outpatient sites of service in a scalable manner; this could be a challenge.  Quick search regarding percent of adults that are hospitalized with uncomplicated CAP yields: older adults (≥65 years) having significantly higher rates, around 1,800-2,000 per 100,000 people yearly, compared to younger adults. Average rate is 20-25% of those with uncomplicated CAP require hospitalization.  This measure doesn't restrict treatment but rather identifies situations for evaluation and discussion with treating facilities regarding their antibiotic prescribing and patient monitoring patterns, to help minimize the incidence of antibiotic resistance.  Overuse of antibiotics can lead to antibiotic resistance, meaning common illnesses are becoming harder to treat.  People are dying from bacterial infections that used to be very treatable.  The pipeline for new antibiotics that can treat resistant strains of infections has slowed down, but the number of resistant bacterial strains is increasing.

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.