COMMENTS AND RESPONSES The Unintended, Negative Consequences of the Door-to-Antibiotic Measure for Pneumonia

TO THE EDITOR: I read with interest the recent article by Wachter and colleagues (1). An additional consequence of policies from the Centers for Medicare & Medicaid Services (CMS) has been the dis-ruption of local pneumonia guideline processes. The 2007 American Thoracic Society–Infectious Disease Society of America pneumonia guideline (2) recommended that “locally adapted guidelines should be implemented to improve process of care variables and relevant clinical outcomes. ” In addition, “CAP [community-acquired pneu-monia] guidelines should address a comprehensive set of elements in the process of care, rather than a single element in isolation.” A guideline was implemented in the Intermountain Healthcare System (Utah and Idaho) beginning in 1995, with a demonstrated decrease in 30-day all-cause mortality and pneumonia admission rates (3, 4). As part of multiple care elements, Intermountain’s guideline recommends specific antibiotics (for example, ceftriaxon