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<h3>Background and Importance</h3> Antimicrobial resistance (AMR) is a major global threat to patient safety and healthcare sustainability. The spread of multidrug-resistant Gram-negative bacteria has limited treatment options and increased costs. Cefiderocol, a siderophore cephalosporin with a unique iron-transport mechanism, is among the few ‘reserve’ antibiotics for infections caused by carbapenem-resistant organisms. Real-world data on its utilisation, appropriateness and economic impact under registry-based monitoring remain scarce. Evaluating these aspects is essential to determine whether registries enhance antimicrobial stewardship and support sustainable access to high-cost, last-resort antibiotics. <h3>Aim and Objectives</h3> To evaluate clinical outcomes, prescriptive appropriateness and economic impact of cefiderocol before and after implementation of a national monitoring registry designed to optimise antimicrobial use in hospital settings. <h3>Material and Methods</h3> A retrospective observational study included adult inpatients treated with cefiderocol before (Mar 2022–Feb 2023; n=19) and after (Mar 2023–Feb 2024; n=16) registry implementation. Collected data: infection type, ward distribution, renal function–based dosing adjustments, therapy duration, discharge or death, vials used and drug expenditure. The economic evaluation was conducted from a healthcare system perspective, considering direct medical costs related to drug acquisition and reimbursement mechanisms. <h3>Results</h3> Thirty-five patients were analysed: nineteen in the pre-registry period and sixteen post-registry. Mortality was 21.1% (4/19) pre-registry and 43.8% (7/16) post-registry. After registry activation, no patient exceeded 21 days of therapy (registry limit), and a reduction in median treatment duration was observed. Renal function–based dose adjustments became more frequent. Vials used decreased from 1,403 to 752 (−46%), and total drug expenditure fell from approximately €2.8 million to €1.5 million. In the post-registry phase, cefiderocol was fully reimbursed through an innovative medicines fund, reducing direct hospital expenditure. <h3>Conclusion and Relevance</h3> Registry-based monitoring of cefiderocol improved governance and supported cost containment without limiting patient access. Eligibility criteria and controlled duration within registries promoted appropriate antibiotic use and helped contain antimicrobial resistance. In 2025, the regulator expanded this model by creating a dedicated fund for reserve antibiotics and extending registry monitoring. These findings emphasise hospital pharmacists’ role in registry-based stewardship and show registries serve as ongoing real-world studies, enabling evaluation of appropriateness, outcomes and sustainability of last-resort antibiotics. <h3>Conflict of Interest</h3> No conflict of interest