# Exploring the perspectives of antimicrobial stewardship pharmacists in England on the subscription model for antimicrobial drugs

## TL;DR

This study explores how antimicrobial stewardship pharmacists in England view a new subscription-based payment model for antibiotics, finding general support but highlighting practical challenges.

## Contribution

The paper provides novel insights from key stakeholders on the implementation and refinement of delinked antimicrobial payment models.

## Key findings

- Most pharmacists support the subscription model and believe it promotes stewardship and innovation.
- Respondents prioritized candidate drugs for pathogens like carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter baumannii.
- Aseptic preparation requirements were identified as the main practical barrier to model implementation.

## Abstract

The National Institute for Health and Care Excellence (NICE) introduced the world's first ‘subscription-type’ antimicrobial payment model in the UK in 2022 for ceftazidime-avibactam and cefiderocol, decoupling reimbursement from usage to stimulate innovation. The model is being expanded to additional antimicrobials. We aimed to explore the views of lead antimicrobial stewardship (AMS) pharmacists, key model implementers and stakeholders, using a nationwide survey.

An online survey was distributed to lead AMS pharmacists of NHS acute Trusts (n = 131) in England (February–July 2025).

Forty-three pharmacists (response rate 32.8%) participated. Most were familiar with the model (86.1%) and supported its principle (88.4%), believing it promotes stewardship and innovation. Strong support existed for model expansion to antifungals, antivirals and novel modalities such as phage therapy.

Key priority pathogens for candidate drugs included carbapenem-resistant Pseudomonas aeruginosa, carbapenem-resistant Acinetobacter baumannii and carbapenem-resistant Enterobacterales. Respondents prioritized candidate drugs with oral or once-daily intravenous administration. Over half (51.2%) favoured empirical use in high-risk patients, the remainder would restrict novel antimicrobials to microbiologically-proven infections. Top risk factors for empirical use included previous infection/colonization with carbapenem-resistant bacteria and carbapenem treatment failure.

Aseptic preparation requirements were the major practical barrier, rather than drug monitoring, storage or interaction management. Median fair price for Trust contribution was 50% of the list cost.

AMS pharmacists view the subscription model positively but highlight the need to refine product award criteria to reflect clinical implementation priorities. Their insights are critical to optimizing future delinked payment models and ensuring equitable access to novel antimicrobials.