Background: Shared decision making (SDM) is a collaborative process between patients and prescribers and identified as a strategy to support antimicrobial stewardship. SDM can improve patient and clinician satisfaction and reduce antibiotic prescribing. However, little is known about how to implement antibiotic SDM in secondary care. Objectives: Identify opportunities for antibiotic SDM between patients and clinicians in secondary care. Methods: Semi-structured interviews were conducted with senior decision makers (registrar or consultant grade) and adult patients who had received antibiotics during their medical or surgical admission, recruited from three secondary care Trusts in England. Interviews explored participants’ views on opportunities for SDM when prescribing antibiotics in secondary care, guided by the ‘Start Smart, Then Focus’ framework. Interviews were audio recorded, transcribed verbatim and analysed thematically. Results: 18 clinicians and 20 patients were interviewed. Two themes were identified. In ‘Pushing back against SDM’, participants challenged the amenability and prioritization of SDM for antibiotics in inpatient settings, related to clinicians being seen as main decision makers, with patients not seeking further involvement. This was reinforced by the perceived urgency of treatment, the fast-paced hospital environment, and the view that antibiotic decisions were either too complex or too straightforward to invite shared input. In ‘If not SDM, then what?’, participants endorsed bi-directional communication and information provision as alternative priorities, highlighting its value. Conclusions: SDM was not well understood or endorsed for antibiotic prescribing decision making in secondary care. Further work is warranted to educate and upskill clinicians in SDM as a concept within secondary care.