P23 The SMASH survey: Subscription Models for Antibiotics in Hospital—preliminary results
Authors: Baltas Ioannis , Gilchrist Mark , Aiken Alexander 
Published: January 2023

Abstract

Objectives
On 1 July 2022 NHS England launched a novel delinked ‘subscription-type’ payment model for two new antimicrobials, ceftazidime/avibactam and cefiderocol. The SMASH survey (Subscription Models for AntibioticS in Hospitals) aims to capture the views of Infectious Diseases and Microbiology Consultants on key knowledge gaps around the implementation and impact of this model in the NHS.

Methods
A novel questionnaire was developed and piloted for this survey (https://www.surveymonkey.co.uk/r/SMASHsurvey). The target audience included Consultants in Infectious Diseases and/or Medical Microbiology working at least 1 day per week (2 Programmed activities or equivalent) in an NHS acute hospital in England. The questionnaire was distributed to all eligible Consultants in England using a network of local investigators in 35 key locations around the country. The SMASH survey was sponsored by the London School of Hygiene and Tropical Medicine (REC Reference No 28161/RR/29296) and funded by an independent research grant from Shionogi B.V.

Results
A total of 111 complete responses were received within the first 21 days of the survey launch. Most responders (55.9%, 62/111) had a CCT in Microbiology or Infectious Diseases and Medical Microbiology (26.1%, 29/111). Only 57.6% (64/111) reported having heard of the new funding model before completing the survey, yet the majority (72.1%, 80/111) agreed that it is a welcome development in the management of drug-resistant infections. Some Consultants reported that cost is a significant consideration when using specific antimicrobials (46.8% Agree or Strongly Agree), while other Consultants were unsure (19.8% Neither Agree or Disagree) or disagreed with this statement (33.4% Disagree or Strongly Disagree). Using a 5-point scoring system and other antimicrobials for carbapenem-resistant infections as comparators, responders indicated that they believed ceftazidime/avibactam and cefiderocol had high insurance (4.28/5 and 4.16/5 respectively) and diversity value (4.11/5 and 4.07/5), moderate enablement (3.37/5 and 3.15/5) and transmission value (3.12/5 and 3.00/5) and low spectrum value (2.13/5 and 2.16/5). Meropenem recorded the highest score for enablement value (3.77/5) and transmission value (3.31/5), while Fosfomycin the highest score for spectrum value (3.06/5). With regards to antimicrobial stewardship, only 20.7% (23/111) of Consultants agreed that the new funding model will lead to reduced use of carbapenems. 46% of responders (51/111) would consider using the two newly introduced antibiotics empirically, when risk factors for antimicrobial resistance are present, while the rest would only use them in microbiologically confirmed carbapenem-resistant infections. The most important resistance risk factors that would justify empirical use were previous infection with carbapenem-resistant bacteria (81.1%), current colonisation with carbapenem-resistant bacteria (73.9%), ward outbreak of carbapenem-resistant bacteria (68.5%), clinical treatment failure of carbapenems (63.1%) and recent admission to high prevalence hospital for carbapenem-resistant bacteria (46.9%).

Conclusions
The ‘subscription type’ payment model for antimicrobials was introduced in England 5 months ago, yet many infection specialists have not been informed about it. Its effect on stewardship is currently uncertain and introduced antimicrobials are likely to be used empirically. Infection specialists in England agree that new antimicrobials have benefits beyond the treatment of an individual patient, especially in terms of insurance and diversity value.