ORIGINAL RESEARCH

370 The Journal for Nurse Practitioners - JNP Volume 8, Issue 5, May 2012

Antimicrobial resistance is one of today’s mosturgent public health problems, threatening toundermine the effectiveness of infectious dis-

ease treatment in every country.1 The pervasive use ofantimicrobial agents is among the most important con-tributors to antimicrobial resistance; of concern, studiesestimate that up to 30%- 50% of all antimicrobial use isinappropriate.2 Multiple studies from various parts ofthe world have demonstrated a strong associationbetween antimicrobial use and resistance, both at theindividual and community level.3 Antibiotic-resistantinfections are associated with a higher mortality ratethan infections caused by the same organisms that arenot resistant to multiple antibiotics,4 and prolongedhospital lengths of stay impose a considerable burden onhealth care systems worldwide.5

Prudent antimicrobial prescribing deserves emergentattention as resistance increases, given the paucity of newantimicrobials in the developmental pipeline. Many new andre-emerging microbial threats, such as methicillin-resistantStaphylococcus aureus (MRSA) and resistant gram-negativeorganisms, continue to challenge health care providers. Overthe past decade, strains of common microbes have devel-oped resistance to drugs that once were effective againstthem. Such antimicrobial-resistant microorganisms, whichdefy conventional therapies, pose a threat to public health.5

To minimize the spread of antimicrobial resistance,both providers and patients must become sufficientlyaware of the public health implications of antimicrobialuse and engage in appropriate antimicrobial use behav-iors.6 Antimicrobial stewardship programs (ASPs) use asystematic approach to optimize antimicrobial therapy

Nurse Practitioners’ Attitudes,Perceptions, and KnowledgeAbout Antimicrobial StewardshipLilian Abbo, MD, Laura Smith, PharmD, Margaret Pereyra, DrPH,Mary Wyckoff, ARNP, and Thomas M. Hooton, MD

ABSTRACTBackground: Antimicrobial resistance is an urgent public health problem. There isvery limited information regarding nurse practitioners’ attitudes, perceptions, andknowledge about antibiotic use and resistance. Methods: Web-based anonymous survey in a university-affiliated hospital.Results: Most respondents agreed that antimicrobial resistance is a problem locallyand nationally, were concerned about resistance in the community when prescribingantibiotics, and agreed that more appropriate use of antibiotics would decrease resist-ance. There is a paucity of knowledge in the management of anaerobic infectionsand resistant gram-negative bacteremia.Conclusion: Incorporating nurse practitioners into antimicrobial stewardship pro-grams could improve evidence-based practices and antimicrobial use.

Keywords: antibiotic use, antimicrobial resistance, antimicrobial stewardship,attitudes, electronic survey, nurse practitioners, perceptions© 2012 American College of Nurse Practitioners

www.npjournal.org The Journal for Nurse Practitioners - JNP 371

through a variety of interventions and have been provento be cost-effective.7,8 In order to curtail inappropriateuse of antimicrobials, ASPs usually promote behaviorchanges by addressing the beliefs and motivations of tar-get groups.9,10 It is well recognized that health careproviders will not alter their management practices unlessthey are both aware of and in agreement with thechanges being proposed.11,12

Even though initiatives have been implemented withinacute and long-term care settings to promote evidence-based, prudent antimicrobial prescribing, most studies haveprimarily targeted the practices of physicians and pharma-cists. Very little consideration has been afforded to the con-tribution nurses can make to antimicrobial management andhow this may impact the development of antimicrobialresistance and health care-associated infections.13 Previoussurveys have been conducted to assess physicians’ knowledgeof and attitudes about antimicrobial use and resist-ance,9,10,14,15 but no published studies have investigatedthese attributes among nurse practitioners (NPs).

NPs are registered nursing professionals who have doc-toral or master’s-level training in a specific specialty and areboard eligible or certified in their specific specialty (eg, fam-ily NP, acute care NP). NPs practice at an autonomous,advanced level and perform multiple roles both for primaryand acute care patients. According to the AmericanAcademy of Nurse Practitioners (AANP), in 2010 therewere approximately 140,000 United States NPs working invarious specialties. Among AANP members, 63% work infamily medicine, 21% in adult medicine, 7% in acute care,and a smaller proportion in women’s health, pediatrics,oncology, and other specialties.16 NPs provide a significantamount of medical care that is likely to increase with healthcare reform17,18; therefore, it is imperative that nurses exhibitsensible antimicrobial-prescribing practices.

The purpose of this study was to assess clinical NPs’attitudes, perceptions, and knowledge toward antibioticuse, antimicrobial resistance, and antimicrobial stewardshipinterventions in a large, university-affiliated, tertiary care,urban hospital.

METHODSIn collaboration with the Centers for Disease Control andPrevention’s (CDC) Division of Healthcare QualityPromotion “Get Smart about Healthcare,” a 68-item Web-based survey, was developed for use at a 1,500-bed tertiarycare center, university-affiliated hospital in Florida. In this

setting, NPs collaborate with attending physicians in patientcare but have autonomous ability to prescribe antimicrobialtherapy. A modified version of the survey instrument thathad been distributed to physicians in the same institutionwas used in this study.19 Demographic questions used in thephysician survey were modified to better assess NPs. Theknowledge, attitudes, and perceptions questions were thesame as in the physicians’ survey.

Demographic information collected included gender,number of years since graduation from NP school, nursingspecialty, and predominant practice setting (inpatient, outpa-tient, or both). The attitudes and perceptions sections had30 and 24 items, respectively. The perceptions sectionincluded questions regarding antibiotic use and resistance, aswell as continuing education resources. Regarding antibioticuse and resistance, a 5-point Likert-response scale, from“strongly agree” to “strongly disagree,” was used; regardingperceptions toward continuing education resources, a 5-point Spector-response scale, from “very useful” to “neveruseful,” was used. Finally, there were 10 multiple-choiceknowledge questions about antimicrobials covering basic tomore advanced topics, each with only 1 correct answer.

After approval of the study by the institutional reviewboard, an electronic invitation letter signed by the studyprincipal investigator and the chief nursing officer was sentwith a link to the survey to all registered NPs in variousspecialties at the time of the study (N � 135) at the hospi-tal. NPs’ e-mail addresses were identified through the hospi-tal’s employee roster; all actively employed NPs were eligibleto participate. Consent was assumed if the respondentopened the survey link. Participation was voluntary andanonymous, and no information was collected from thosewho decided not to participate.

The survey was Internet-based, using SurveyMonkey.com®, and was available online for 6 weeksbetween August 23 and November 4, 2009. During thisperiod, an e-mail reminder was sent every 2 weeks to alleligible participants. No incentives for participation weregiven. Data analyses were performed with Stata version 9(StataCorp LP, College Station, TX). Descriptive statisticsincluded percentages for categorical measures. Differencesby gender were assessed with chi-square tests.

The instrument developers—who included infectiousdiseases physicians, a clinical pharmacist, and a behavioralscientist—pretested the survey among a select group ofmedical students and resident and faculty physicians. Onlyface validity of the instrument was assessed, as most items

372 The Journal for Nurse Practitioners - JNP Volume 8, Issue 5, May 2012

relate to actual behaviors or knowledge. No psychometricanalyses were performed because summary measures werenot constructed for analyses other than a knowledge score.

RESULTSDemographicsForty-three percent (58/135) of the NPs completed thequestionnaire. The respondents were 88% female; 66% hadgraduated in their area of specialty as an NP 7 or moreyears ago, 24% 2-6 years ago, and 10% within 1 year beforetaking the survey. Among the 58 respondents, 53% reportedthat they usually prescribe antibiotics mostly for hospitalizedpatients, 34% mostly for outpatients, and 12% for both.Respondents varied widely in their area of specialty: 26% incritical care, 12% obstetrics and gynecology, and a smallernumber of participants from other departments, such as sur-gery, emergency medicine, neurosurgery, hospital medicine,internal medicine, orthopedics, physical medicine and reha-bilitation, transplant surgery, and ambulatory primary care.

Attitudes Toward Antimicrobial UseThe factors that might influence NPs’ decision to usean antibiotic are summarized in Table 1. Most respon-dents agreed that risk of missing an infection (67%) ortreating a sick or immunocompromised patient (89%)would “often or always” affect their decision to select anantibiotic in general.

Table 2 summarizes the respondents’ attitudes towardthe empiric selection of antibiotics in patients with no cul-ture information. Sixty percent of the respondents said theywould start with broad-spectrum agents and tailor uponreceiving culture results, 21% gave open-ended answers (eg,following a unit-specific antibiogram), and others said theydo not usually prescribe antibiotics. There were no statisti-cally significant differences by gender or specialty in theempiric selection of antibiotics.

Perceptions About Antibiotic Use and ResistancePerceptions about antibiotic use and resistance are sum-marized in Table 3. Overall, 93% of the respondentsagreed or strongly agreed that antibiotics are overusednationally, but only 54% agreed that antibiotics are over-used locally. Most respondents disagreed or strongly dis-agreed with the statement that antimicrobial resistance isnot a significant problem nationally and locally (93% and90%, respectively). Similarly, almost all respondents agreedthat inappropriate use of antibiotics can harm patients(96%) and that inappropriate use of antibiotics causesantimicrobial resistance (98%).

Overall, 83% of respondents agreed or strongly agreedthey were concerned about antimicrobial resistance inthe community when prescribing an antibiotic; femalerespondents (85%) were more likely to agree than males(60%; P � 0.051). Only 4% of the respondents agreed

Table 1. Frequency Distribution (% Response) of Attitudes That Might Influence NP Decision to Select an Antibioticin General

Consideration Never/Rarely Sometimes Often/Always nCost savings for the patient 7.1% 23.2% 69.6% 56

Cost savings for the hospital 14.3% 26.8% 58.9% 56

Risk of missing an infection 8.8% 24.6% 66.7% 57

Patient demands and expectations 78.6% 10.7% 10.7% 56for antibiotics

Patient is critically ill or 5.4% 5.4% 89.3% 56immunocompromised

Reassurance when using an antibiotic, 80.0% 12.7% 7.3% 55even if it might be the wrong one

Unexplained fever or leukocytosis, 33.9% 50.0% 16.1% 56even if cultures are negative

Treat colonization to prevent infection 44.6% 33.9% 21.4% 56

Risk of developing Clostridium 37.3% 37.3% 25.5% 51difficile colitis

Other 30.8% 23.1% 46.2% 13

www.npjournal.org The Journal for Nurse Practitioners - JNP 373

that they themselves overprescribe antibiotics, and 6%agreed that other NPs overprescribe antibiotics. Mostrespondents (97%) agreed that strong knowledge ofantibiotics is important to their health care careers.

Perceptions Toward Continuing Education ResourcesPerceptions toward the most useful resources regarding edu-cation about antibiotics are summarized in Table 4. Overall,66% of the respondents were not familiar with the ASP, andonly 17% perceived it as a useful or very useful resource.Infectious diseases colleagues (75%), medical journals (71%),and continuing education courses or live lectures (60%)were rated as the most useful resources.

KnowledgeThe mean score (percentage of correct answers to the 10questions) in the antibiotic knowledge test was 69%, with arange of 40% to 100%. There was no significant differencein the mean knowledge score by gender or years of experi-ence in specialty. Critical care NPs scored higher than thosein other specialties (82% vs 64%; P � 0.002), and thosewhose primary care setting was in the inpatient area scoredhigher than the ones who spent most of their time in out-patient care settings (76% vs 61%; P � 0.042).

Knowledge scores were highest for questions on theappropriate selection of antimicrobials for the managementof MRSA bacteremia (83%), prevention of catheter-associ-ated urinary tract infections (95%), and identification of themost expensive oral antibiotic (93%). Mean scores werelowest for questions about management of anaerobic infec-tions (33%) and extended spectrum beta-lactamase (ESBL)

positive bacteremia (28%). Only 65% scored correctly onthe key determinant of survival in the treatment of pneu-monia, and 68% correctly selected the most appropriateantibiotic regimen for surgical prophylaxis.

DISCUSSIONSince the 1970s, studies have shown that NPs consistentlyprovide primary care that is similar in quality to physiciansand that NPs have the ability to appropriately prescribedrugs independently.20 NPs’ antimicrobial prescribing pat-terns (both appropriate and inappropriate) for viral infec-tions have been shown to be similar to those of physiciansaccording to some17,21 but not all22 authors. Roumie et al22

compared outpatient antibiotic prescribing patterns byphysicians, nonphysician clinicians (NPs and physician assis-tants), and resident physicians using large national databases.For all patient visits, nonphysician clinicians were morelikely to prescribe antibiotics than physicians in office prac-tices (26.3% vs 16.2%), emergency departments (23.8% vs18.2%), and hospital clinics (25.2% vs 14.6%), suggestingthat appropriate antimicrobial prescribing campaigns havenot reached all providers, including NPs.

Sym et al23 surveyed 312 NP programs across the USto examine NP curricula with regard to antibiotics andantimicrobial resistance and assess the need for a Web-based module for instruction on antimicrobial resistance.Interestingly, 99.3% of the respondents in that studyrequired a pharmacology course and 95% had lecturesdedicated to antimicrobial therapy. In general, NP curric-ula include fewer than 10 hours of content on antimicro-bial therapy, and 52% of the programs did not offer a

Policy Implications

University nurse practitioner programs shoulddevelop collaborative efforts to incorporate moreantimicrobial stewardship education into their cur-ricula. In the near future, educational modules withclinical scenarios could be used to reinforce aware-ness of the importance of appropriate antimicrobialprescribing as part of board recertification and tomaintain hospital/license practicing privileges.Departments of Health and nursing schools coulddevelop collaborations for ambulatory care settingswhere a significant amount of antimicrobials are pre-scribed in the community.

Table 2. Frequency Distribution of NP Attitudes Towardthe Empiric Selection of an Antibiotic in aPatient With no Culture Information (N = 58)

Response PercentageI start with broad spectrum and 60.3

tailor upon culture results.

I base my decisions on the 29.3hospital antibiogram.

I ask a resident. 1.7

I ask an attending physician. 17.2

I ask another NP or PA. 5.2

I use the same 1 or 2 antibiotics. 6.9

I ask the patient. 1.7

Other 20.7

374 The Journal for Nurse Practitioners - JNP Volume 8, Issue 5, May 2012

microbiology course. These results suggest that there areopportunities to improve baseline and continuous knowl-edge about antibiotic use and resistance among NPs.

This study revealed that NPs share many but not all ofthe attitudes and perceptions about antibiotic use as physi-cians.19 Thus, NPs are highly aware and concerned about

overuse of antibiotics, and most agree that antibiotics areoverused nationally, similar to the results found in previousstudies conducted in faculty and resident physicians.9,15,19 Inthis study, NPs agreed that antimicrobial resistance is a sig-nificant problem both locally and nationally, which is consis-tent with perceptions among physicians. Whereas 62% of

Table 3. Frequency Distribution of Perceptions Among NPs About Antimicrobial Use and Resistance

Disagree or Strongly Agree or Strongly Perceptions Disagree Neutral Agree nAntibiotics are overused nationally. 5.3% 1.8% 93.0% 57

Antibiotics are overused in my hospital. 7.2% 39.3% 53.6% 56

Antibiotic resistance is a not significant problem nationally. 92.7% 1.8% 5.5% 55

Antibiotic resistance is not a significant problem in my hospital. 89.5% 1.8% 8.8% 57

Better use of antibiotics will reduce 0.0% 0.0% 100.0% 57problems with antimicrobial resistance.

Strong knowledge of antibiotics is 0.0% 3.5% 96.5% 57important in my health care career.

I am confident that I use antibiotics optimally in the ICU. 4.7% 46.5% 48.8% 43

I am confident that I use antibiotics 1.9% 17.3% 80.8% 52optimally in the non-ICU setting.

I overprescribe antibiotics. 91.2% 5.3% 3.5% 57

Other NPs overprescribe antibiotics. 33.3% 61.1% 5.6% 54

Antibiotic management programs are 66.1% 14.3% 19.7% 56an obstacle to good patient care.

I would like more feedback on my antibiotic selections. 9.1% 18.2% 72.7% 55

I would like more education on antibiotics. 1.8% 7.0% 91.2% 57

I am less likely to use restricted antibiotics if infectious 35.1% 14.0% 50.9% 57disease approval is required.

Interactions with pharmaceutical representatives do not 17.0% 20.8% 62.3% 53influence my antibiotic selections.

Locally developed guidelines for antibiotic treatment 17.0% 26.4% 56.6% 53would be more useful than national ones.

I am concerned about antimicrobial resistance in the 1.9% 15.1% 83.0% 53community when I prescribe antibiotics.

I am concerned about antimicrobial resistance in my 3.8% 7.6% 88.7% 53hospital when I prescribe antibiotics.

New antibiotics will be developed in the future that 34.0% 34.0% 32.1% 53will keep up with the problem of “resistance.”

Prescribing broad spectrum antibiotics when equally 9.4% 18.9% 71.7% 53effective narrower ones are available increases antimicrobial resistance.

Poor infection control practices by health care 7.6% 13.2% 79.3% 53professionals causes spread of antimicrobial resistance.

Inappropriate use of antibiotics causes antimicrobial resistance. 0.0% 1.9% 98.1% 53

Inappropriate use of antibiotics can harm patients. 0.0% 3.8% 96.2% 53

Inappropriate use of antibiotics is professionally unethical. 3.8% 18.9% 77.4% 53

www.npjournal.org The Journal for Nurse Practitioners - JNP 375

physicians in this institution agreed that other physiciansversus 13% of themselves overprescribe antibiotics, only 6%of the NPs agreed that other NPs overprescribe antibiotics,compared with 4% of themselves. Data on individual pre-scribing practices were not collected in this and the previousphysician survey20 (both were anonymous), so the explana-tion for this large difference is unknown. However, it seemslikely that NPs are as likely to prescribe antibiotics inappro-priately as often as physicians, and this perception seems areasonable target for antimicrobial stewardship interventionsin both groups.

Most NPs agreed that knowledge of antibiotics isimportant and that they would like more educationand feedback about their selections. At this institution,the ASP traditionally has operated with front-endantibiotic preapproval authorization and restrictions.Because of several issues, prospective audit and feed-back have been limited to certain areas, and perhapsthat explains why 66% of the survey respondents werenot familiar with the ASP as a source for continuingeducation about antibiotics.

NPs at this institution said they would welcome feed-back on their antibiotic selections as part of future ASPinterventions and clinical pathways; respondents also agreedthat locally developed guidelines for antibiotic treatment aremore useful than national ones. These perceptions suggestthat guidelines promoted by ASPs are likely to meet withmore success if the programs take into consideration localpractices and resistance patterns. NPs should be engaged as

part of multidisciplinary ASPs to improve antimicrobial usein outpatient and inpatient practice settings.

NPs have important gaps in knowledge regarding theappropriate use of antibiotics for anaerobic and gram-nega-tive resistant infections (similar to the physicians),19 and thisrepresents an opportunity for education. Future educationalefforts perhaps must be interlaced with feedback to pre-scribers regarding their antimicrobial use and local patternsof resistance emphasizing these areas.

Potential study limitations include the low responserate. The rate was likely a result, in part, to the manyfunctions of hospital-based NPs that do not requireantibiotics, which may have led some of them to notanswer the survey. It is also possible that some NPs donot perceive antimicrobial use and resistance to be aproblem and thus elected not to participate in the study.Other limitations are that the questionnaire was self-reported, had not been externally validated, and was con-ducted in a single institution.

Study strengths are that this is the first survey studylooking at NPs’ knowledge, attitudes, and perceptionstoward antibiotic use, resistance, and antimicrobial stew-ardship interventions. The survey was Web-based andallowed rapid distribution and turnaround time forresponses; it was also anonymous, which likely reducedthe tendency of respondents to provide “socially desir-able” answers. In the future, this survey could be vali-dated and applied across facilities engaging NPs inantimicrobial stewardship.

Table 4. Frequency Distribution of NPs’ Perceptions Toward Various Educational Resources as a Source forContinuous Education on Antibiotics

Resource Useful or Very Useful Not Familiar nAntimicrobial Stewardship Program 17.0% 66.0% 53

Ward rotations 38.0% 30.0% 50

Grand rounds 51.0% 9.8% 51

Infectious diseases colleagues (fellows or faculty) 75.0% 9.6% 52

Pharmaceutical representatives 45.3% 9.4% 53

Off-campus lecture sponsored by pharmaceutical company 34.0% 7.6% 53

CE online or live lectures 60.4% 1.9% 53

Medical journals 71.2% 1.9% 52

Sanford Guide 58.5% 17.0% 53

UptoDate 58.5% 13.2% 53

Google 47.2% 1.9% 53

Internet Web sites 44.7% 6.4% 47

376 The Journal for Nurse Practitioners - JNP Volume 8, Issue 5, May 2012

CONCLUSIONSGiven the increasing social and economic burden of antimi-crobial resistance and health care-associated infections, it iscritical that health care professionals work together acrossdisciplines to maximally benefit patients.13 These data sug-gest that antimicrobial stewardship efforts should target NPsand physicians, and several areas have been highlightedwhere intervention activities may be targeted. The results ofthis survey may be helpful in assessing barriers and facilita-tors in implementing antimicrobial stewardship interven-tions targeting NPs in institutions with large numbers thatprescribe antimicrobials and with a high prevalence ofantimicrobial resistance. This study also highlights potentialopportunities for interdisciplinary efforts with infectioncontrol and public health departments.

References

1. Spellberg B, Guidos R, Gilbert D, et al. The epidemic of antibiotic-resistantinfections: a call to action for the medical community from the InfectiousDiseases Society of America. Clin Infect Dis. 2008;46(2):155-164.

2. Owens RC Jr, Shorr AF, Deschambeault AL. Antimicrobial stewardship:shepherding precious resources. Am J Health Syst Pharm. 2009;66(12 Suppl4):S15-22.

3. Goldstein EJ. Beyond the target pathogen: ecological effects of the hospitalformulary. Curr Opin Infect Dis. 2011;24(Suppl 1):S21-31.

4. Patel G, Huprikar S, Factor SH, Jenkins SG, Calfee DP. Outcomes ofcarbapenem-resistant Klebsiella pneumoniae infection and the impact ofantimicrobial and adjunctive therapies. Infect Control Hosp Epidemiol.2008;29(12):1099-1106.

5. de Kraker ME, Davey PG, Grundmann H. Mortality and hospital stayassociated with resistant Staphylococcus aureus and Escherichia colibacteremia: estimating the burden of antibiotic resistance in Europe. PLoSMed. 2011;8(10).

6. Edgar T, Boyd SD, Palame MJ. Sustainability for behaviour change in thefight against antibiotic resistance: a social marketing framework. JAntimicrob Chemother. 2009;63(2):230-237.

7. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society ofAmerica and the Society for Healthcare Epidemiology of America guidelinesfor developing an institutional program to enhance antimicrobialstewardship. Clin Infect Dis. 2007;44(2):159-177.

8. Strategy for the Control of Antimicrobial Resistance in Ireland. Guidelinesfor Antimicrobial Stewardship in Hospitals in Ireland. Hospital AntimicrobialStewardship Working Group Web site. 2009. http://www.hpsc.ie/hpsc/.Accessed January 23, 2012.

9. Guerra CM, Pereira CA, Neves Neto AR, Cardo DM, Correa L. Physicians’perceptions, beliefs, attitudes, and knowledge concerning antimicrobialresistance in a Brazilian teaching hospital. Infect Control Hosp Epidemiol.2007;28(12):1411-1414.

10. Giblin TB, Sinkowitz-Cochran RL, Harris PL, et al. Clinicians’ perceptions ofthe problem of antimicrobial resistance in health care facilities. Arch InternMed. 2004;164(15):1662-1668.

11. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinicalpractice guidelines? A framework for improvement. JAMA. 1999;282(15):1458-1465.

12. Abboud PA, Cabana MD. Understanding barriers to the adoption of clinicaldecision rules. Ann Emerg Med. 2001;38(6):703-704.

13. Edwards R, Drumright L, Kiernan M, Holmes A. Covering more territory tofight resistance: Considering nurses’ role in antimicrobial stewardship. JInfect Prev. 2011;12(1):6-10.

14. Antoine TL, Curtis AB, Blumberg HM, et al. Knowledge, attitudes, andbehaviors regarding piperacillin-tazobactam prescribing practices: resultsfrom a multicenter study. Infect Control Hosp Epidemiol. 2006;27(11):1274-1277.

15. Srinivasan A, Song X, Richards A, Sinkowitz-Cochran R, Cardo D, Rand C. Asurvey of knowledge, attitudes, and beliefs of house staff physicians fromvarious specialties concerning antimicrobial use and resistance. Arch InternMed. 2004;164(13):1451-1456.

16. American Academy of Nurse Practitioners Annual Report 2010. http://www.aanp.org/NR/rdonlyres/97CD0283-59DF-4964-819B-61E58864B4F8/0/2010AANP_AnnualReport.pdf. Accessed January 25, 2012.

17. Running A, Kipp C, Mercer V. Prescriptive patterns of nurse practitioners andphysicians. J Am Acad Nurse Pract. 2006;18(5):228-233.

18. Pickert K. If a health-care bill passes, nurse practitioners could be key.TIME.com: August 3, 2009. http://www.time.com/time/nation/article/0,8599,1914222,00.html. Accessed January 25, 2012.

19. Abbo L, Sinkowitz-Cochran R, Smith L, et al. Faculty and residentphysicians' attitudes, perceptions, and knowledge about antimicrobial useand resistance. Infect Control Hosp Epidemiol. 2011;32(7):714-718.

20. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patientstreated by nurse practitioners or physicians: a randomized trial. JAMA.2000;283(1):59-68.

21. Ladd E. The use of antibiotics for viral upper respiratory tract infections: ananalysis of nurse practitioner and physician prescribing practices inambulatory care, 1997-2001. J Am Acad Nurse Pract. 2005;17(10):416-424.

22. Roumie CL, Halasa NB, Edwards KM, Zhu Y, Dittus RS, Griffin MR.Differences in antibiotic prescribing among physicians, residents, andnonphysician clinicians. Am J Med. 2005;118(6):641-648.

23. Sym D, Brennan CW, Hart AM, Larson E. Characteristics of nursepractitioner curricula in the United States related to antimicrobialprescribing and resistance. J Am Acad Nurse Pract. 2007;19(9):477-485.

Lilian Abbo, MD, is an assistant professor of clinical medicine in thedivision of infectious diseases at the University of Miami MillerSchool of Medicine and medical director of the AntimicrobialStewardship Program at Jackson Memorial Hospital in Miami, FL.She can be reached at Labbo@med.miami.edu. Laura Smith,PharmD, BCPS, is a clinical pharmacist in infectious diseases atthe same hospital and pharmacy director of the AntimicrobialStewardship Program. Margaret Pereyra, DrPH, is a research assis-tant professor in the University of Miami department of epidemiol-ogy and public health. Mary Wyckoff, ARNP, is an acute care nursepractitioner and director of education and research in critical care atthe William Lehman Injury Research Center and an assistant pro-fessor in the University of Miami School of Nursing. Thomas M.Hooton, MD, is professor of clinical medicine in the department ofmedicine and medical director of infection control and occupationalhealth at the University of Miami. In compliance with national eth-ical guidelines, the authors report no relationships with business orindustry that would pose a conflict of interest.

AcknowledgmentsThe authors appreciate the assistance of Ronda Sinkowitz-Cochran, MPH, and Arjun Srinivasan, MD, at the Centers forDisease Control and Prevention, Division of HealthcareQuality and Promotion, for their thoughtful review of the sur-vey and the final manuscript.

1555-4155/12/$ see front matter© 2012 American College of Nurse Practitionersdoi: 10.1016/j.nurpra.2012.01.023