1st November 2022

There is ever-increasing worldwide awareness that antimicrobial resistance (AMR) poses a threat to global heath. Despite this, the pipeline for developing new antimicrobial drugs remains alarmingly empty. No new classes of antibiotics have been discovered since the 1980s and novel agents in existing classes are rarely used, due to their significant cost. To address this problem, in July 2022, NHS England launched a “subscription-type” payment model for two novel antimicrobials, ceftazidime/avibactam and cefiderocol, also known as the “Netflix” model. This is the first use of such a funding model for antimicrobials in the world. Here, Dr Ioannis Baltas, a trainee at Imperial College Healthcare NHS Trust in London, explains how an England-wide survey of Infectious Diseases and Microbiology Consultants will inform the evaluation of this funding model.

“The problem of new antibiotic development is tricky. There is clearly an enormous international need for new treatments for AMR. Having grown up in Greece, I saw many patients with resistant infections getting old, toxic treatments, because new treatments were too expensive. Ironically, this further drove resistance, as a narrow pool of agents was recycled again and again. Parts of the UK are not far away from being in the same situation.”

“On the other hand, I can see why pharmaceutical companies have largely exited the antibiotic market. New antimicrobials are expensive and difficult to develop and get licensed. When eventually a new one gets through, doctors use it very sparingly to avoid driving resistance. This pay-per-use approach creates a high risk, low reward market for the drug companies, that will not encourage anyone to try to develop new drugs”.

“I think NHS England and NICE have done something exciting with this new funding model: it addresses both the clinical need to use existing new antibiotics and the market failure for pharmaceutical companies to develop new agents. Importantly, it aligns good antimicrobial stewardship with industry financial incentives: profits for companies are now guaranteed by being delinked from usage, so it is in everyone’s interest that the new antibiotics stay on the shelf. There, they can act as insurance in case resistance arises, yet still be available for all patients who need them, without cost considerations”.

“The introduction of this model puts England in the international spotlight of AMR policy research. Many countries, including the USA and European nations are considering implementing similar models: their decisions will depend heavily on data arising from this “English experiment”, including understanding how front-line services across the country respond to the model.”

“One of the knowledge gaps that arose during the NICE negotiation process for the “subscription-type” model, was about its real-life implementation in the NHS: will practitioners now consider that empirical use is justified now that these drugs are cheaper? What limitations on usage will individual Trusts employ for these agents? What is the value of the availability of novel antibiotics to the wider NHS, beyond the treatment of individual patients?”

“To answer these questions, we set up the SMASH survey (Subscription Models for AntibioticS in Hospital)*. SMASH aims to capture the views of Infectious Diseases and Microbiology Consultants on the implementation and impact of the subscription-type payment model in the NHS in England, in order to inform future health policy in the UK and beyond. It is important to note that SMASH collects information complimentary to the UK Antimicrobial Registry,set up by BSAC, which primarily focuses on patient outcomes. Both forms of evaluation will be important to establish the true value of this funding model”.

“The SMASH survey will run in November and December 2022. If you are a Consultant in Infectious Diseases or Microbiology in England, you should be approached by a local study investigator and invited to complete the survey. The questionnaire should take approximately 20 minutes to complete, and a £10 Amazon voucher is offered to thank you for your participation”.

Interested in completing the SMASH survey, influence future health policy and improve the care of patients with drug-resistant infections in England? You can access the survey here

*The study is conducted by the London School of Hygiene and Tropical Medicine (REC Reference No 28161/RR/29296) and is funded by an independent research grant from Shionogi B.V. The funder of this study has had/will have no role in the design, conduct or interpretation of this study, nor will details of study participants be shared with the funder of this study.

Ioannis is currently an IMT-2 doctor in Hammersmith Hospital, part of Imperial College Healthcare NHS Trust. He completed his undergraduate training in Greece, where he witnessed firsthand the burden of antimicrobial resistance. He moved to the UK in 2017 to study the MSc Immunology of Infectious Diseases in the London School of Hygiene and Tropical Medicine. He then started his clinical training and completed the foundation program in 2020. After this, he took a year out to study the Diploma in Tropical Medicine and Hygiene and a Postgraduate Certificate in Medical Education, while also gaining clinical experience in Virology in the Royal Free Hospital. His dream is to specialize in Infectious Diseases and Medical Microbiology and follow a combined clinical and academic career. His research interests include antimicrobial resistance, antimicrobial stewardship and medical education.

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