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LETTERS TO THE EDITOR
combinations in which more than 20% of frequencies were less than five. Statistical significance was defined as a P < .05. A comparison of the rates of susceptibility between the age-stratified antibiograms can be seen in Table 1. Statistically significant differences were identified for four combinations of species and antimicrobial agents: Proteus mirabilis and ampicillin (P = .004), Proteus mirabilis and cefazolin (P = .01), Staphylococcus aureus and clindamycin (P = .01), and Enterococcus faecalis and levofloxacin (P = .02). Despite these differences, the facilitywide antibiogram did not overestimate susceptibility rates from the geriatric antibiogram. Rates of resistance were generally seen to be higher in the geriatric antibiogram (Table 1). Within the WJB Dorn VAMC, the age-stratified geriatric antibiogram created during this study was not found to be significantly different from the 2013 facility-wide antibiogram. In a previously published study, hospitalwide, age- and location-stratified susceptibility results were analyzed for Staphylococcus aureus, Escherichia coli, and Streptococcus pneumoniae and lower antibiotic susceptibility was found in older adults, which was obscured in the institution-wide antibiogram.3 The health system from which the aforementioned results were identified serves a much more diverse population than a VAMC. At a VAMC, all final culture and sensitivity data used to create the annual facility-wide antibiogram come from isolates collected from adults. It is likely that this difference in the core population, as well as the high rates of older adults served at the WJB Dorn VAMC, resulted in the minimal differences found between the geriatric and facility-wide antibiograms. This study has several limitations. Combinations of species and antimicrobial agents assessed were heavily reliant on the culture and sensitivity data merged into the electronic medical record. Sample size and number of resistant isolates are much smaller when data are separated into age-stratified groupings; the small sample size may have obscured or overemphasized trends in resistance. Because of differences in the sampling methods between the facility-wide and age-stratified antibiograms, statistical analysis could not be performed to assess possible differences more completely. In summary, susceptibility data for older adults as interpreted through the geriatric antibiogram were not overestimated in the WJB Dorn VAMC facility-wide antibiogram, so an alternative antibiogram does not need to be created for older adults cared for at this VAMC and associated community-based outpatient clinics at this time. As the average age of the population served at VAMCs continues to decrease because of increased enrollment of Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn veterans, it may be necessary to revisit this topic in the future. MaryAnne M. Ventura, PharmD Kevin Brittain, PharmD William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, South Carolina
JANUARY 2015–VOL. 63, NO. 1
JAGS
Jennifer Pruskowski, PharmD William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, South Carolina James J. Peters Veterans Affairs Medical Center, Bronx, New York Diana Hogan, PharmD Tiffany Walker, PharmD William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, South Carolina
ACKNOWLEDGMENTS The authors would like to acknowledge Dr. Christie DeBruhl for her assistance with development of methods and Dr. Aubrey Cartwright for reviewing the manuscript. Conflict of Interest: There are no financial or personal conflicts of interest for authors. Author Contributions: Ventura: data collection, analysis, and interpretation; manuscript preparation. Brittain: study concept and design, data analysis and interpretation, manuscript review. Pruskowski, Walker: study concept and design, manuscript review. Hogan: data analysis and interpretation, manuscript review. Sponsor’s Role: None.
REFERENCES 1. Lacy MK, Klutman NE, Horvat RT et al. Antibiograms: New NCCLS guidelines, development and clinical application. Hosp Pharm 2004;39:542– 553. 2. Clinical and Laboratory Standards Institute. Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data, 3rd Ed. (Approved guideline M39-A3). Wayne, PA: Clinical and Laboratory Standards Institute, 2009. 3. Swami SK, Banerjee R. Comparison of hospital-wide and age and locationstratified antibiograms of S. aureus, E. coli, and S. pneumoniae: Age- and location-stratified antibiograms. Springerplus 2013;2:63. 4. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60:616– 631.
CUTANEOUS SURGERY COMPLICATIONS IN INDIVIDUALS AGED 80 AND OLDER VERSUS YOUNGER THAN 80 AFTER EXCISION OF NONMELANOMA SKIN CANCER To the Editor: Nonmelanoma skin cancer (NMSC) is the most common cancer worldwide, and its incidence is increasing;1 these facts and the aging of the population in the developed world suggest that dermatologists will be faced with an increasing number of very elderly adults presenting with skin cancers.2 Several studies have analyzed the outcome of surgery in elderly adults in other surgical disciplines but few in dermatological surgery. Some authors have demonstrated that skin surgery is a safe and effective therapy in elderly adults.3 The most important decision is how best to treat these patients with these skin conditions that progress slowly and are usually not fatal.4
JAGS
JANUARY 2015–VOL. 63, NO. 1
LETTERS TO THE EDITOR
189
Table 1. Baseline Demographic Characteristics and Complications According to Age Characteristic
Age, mean ( standard deviation) Male (%) Charlson Comorbidity Index, n (%) 0–1 2 ≥3 Main comorbidities, n (%) Uncomplicated diabetes mellitus Dementia Acute myocardial infarction Congestive heart failure Stroke Surgical technique, n (%) Excision and direct closure Excision and flap Excision and graft Surgical complications, n (%) Wound infection Hemorrhagic complication Dehiscence Flap or graft necrosis Incompletely excised tumors, n (%)
≥80, n = 130
.99 4 (times)
3)
5)
4)
6)
Figure 1. (A) Cross-sectional association between glucose intolerance and instrumental activity of daily living (IADL) disability at baseline (N = 378). P < *.05, **0.01 using multiple logistic regression. (B) Longitudinal association between glucose intolerance and IADL decline over 5 years (n = 289). #P < .10 using multiple logistic regression. (C) Protective effect of participation of follow-up on IADL decline over 5 years in impaired glucose tolerance (IGT) and normal glucose tolerance (NGT) groups (n = 289). *P < .05 (NGT), †P < .05 (IGT) using multiple logistic regression. DM = diabetes mellitus.
P = .04), depression (OR = 2.77, 95% CI = 0.94–8.15, P = .06), age, sex, falling, and BMI (Figure 1B). All subjects were invited to participate in the five annual glucose intolerance and geriatric functional analyses and education about lifestyle modification during the 5-year study period.5,10 To analyze the preventive effect of followup participation of participants with NGT, IGT and DM on IADL decline, all subjects were assigned to one of two groups: more participation (≥4) or less participation (≤3). 1 NGT IADL 2 NGT IADL
with less participation (n = 108, 16.7% with decline). with more participation (n = 62, 14.5% with decline).
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
LETTERS TO THE EDITOR
combinations in which more than 20% of frequencies were less than five. Statistical significance was defined as a P < .05. A comparison of the rates of susceptibility between the age-stratified antibiograms can be seen in Table 1. Statistically significant differences were identified for four combinations of species and antimicrobial agents: Proteus mirabilis and ampicillin (P = .004), Proteus mirabilis and cefazolin (P = .01), Staphylococcus aureus and clindamycin (P = .01), and Enterococcus faecalis and levofloxacin (P = .02). Despite these differences, the facilitywide antibiogram did not overestimate susceptibility rates from the geriatric antibiogram. Rates of resistance were generally seen to be higher in the geriatric antibiogram (Table 1). Within the WJB Dorn VAMC, the age-stratified geriatric antibiogram created during this study was not found to be significantly different from the 2013 facility-wide antibiogram. In a previously published study, hospitalwide, age- and location-stratified susceptibility results were analyzed for Staphylococcus aureus, Escherichia coli, and Streptococcus pneumoniae and lower antibiotic susceptibility was found in older adults, which was obscured in the institution-wide antibiogram.3 The health system from which the aforementioned results were identified serves a much more diverse population than a VAMC. At a VAMC, all final culture and sensitivity data used to create the annual facility-wide antibiogram come from isolates collected from adults. It is likely that this difference in the core population, as well as the high rates of older adults served at the WJB Dorn VAMC, resulted in the minimal differences found between the geriatric and facility-wide antibiograms. This study has several limitations. Combinations of species and antimicrobial agents assessed were heavily reliant on the culture and sensitivity data merged into the electronic medical record. Sample size and number of resistant isolates are much smaller when data are separated into age-stratified groupings; the small sample size may have obscured or overemphasized trends in resistance. Because of differences in the sampling methods between the facility-wide and age-stratified antibiograms, statistical analysis could not be performed to assess possible differences more completely. In summary, susceptibility data for older adults as interpreted through the geriatric antibiogram were not overestimated in the WJB Dorn VAMC facility-wide antibiogram, so an alternative antibiogram does not need to be created for older adults cared for at this VAMC and associated community-based outpatient clinics at this time. As the average age of the population served at VAMCs continues to decrease because of increased enrollment of Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn veterans, it may be necessary to revisit this topic in the future. MaryAnne M. Ventura, PharmD Kevin Brittain, PharmD William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, South Carolina
JANUARY 2015–VOL. 63, NO. 1
JAGS
Jennifer Pruskowski, PharmD William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, South Carolina James J. Peters Veterans Affairs Medical Center, Bronx, New York Diana Hogan, PharmD Tiffany Walker, PharmD William Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, South Carolina
ACKNOWLEDGMENTS The authors would like to acknowledge Dr. Christie DeBruhl for her assistance with development of methods and Dr. Aubrey Cartwright for reviewing the manuscript. Conflict of Interest: There are no financial or personal conflicts of interest for authors. Author Contributions: Ventura: data collection, analysis, and interpretation; manuscript preparation. Brittain: study concept and design, data analysis and interpretation, manuscript review. Pruskowski, Walker: study concept and design, manuscript review. Hogan: data analysis and interpretation, manuscript review. Sponsor’s Role: None.
REFERENCES 1. Lacy MK, Klutman NE, Horvat RT et al. Antibiograms: New NCCLS guidelines, development and clinical application. Hosp Pharm 2004;39:542– 553. 2. Clinical and Laboratory Standards Institute. Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data, 3rd Ed. (Approved guideline M39-A3). Wayne, PA: Clinical and Laboratory Standards Institute, 2009. 3. Swami SK, Banerjee R. Comparison of hospital-wide and age and locationstratified antibiograms of S. aureus, E. coli, and S. pneumoniae: Age- and location-stratified antibiograms. Springerplus 2013;2:63. 4. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60:616– 631.
CUTANEOUS SURGERY COMPLICATIONS IN INDIVIDUALS AGED 80 AND OLDER VERSUS YOUNGER THAN 80 AFTER EXCISION OF NONMELANOMA SKIN CANCER To the Editor: Nonmelanoma skin cancer (NMSC) is the most common cancer worldwide, and its incidence is increasing;1 these facts and the aging of the population in the developed world suggest that dermatologists will be faced with an increasing number of very elderly adults presenting with skin cancers.2 Several studies have analyzed the outcome of surgery in elderly adults in other surgical disciplines but few in dermatological surgery. Some authors have demonstrated that skin surgery is a safe and effective therapy in elderly adults.3 The most important decision is how best to treat these patients with these skin conditions that progress slowly and are usually not fatal.4
JAGS
JANUARY 2015–VOL. 63, NO. 1
LETTERS TO THE EDITOR
189
Table 1. Baseline Demographic Characteristics and Complications According to Age Characteristic
Age, mean ( standard deviation) Male (%) Charlson Comorbidity Index, n (%) 0–1 2 ≥3 Main comorbidities, n (%) Uncomplicated diabetes mellitus Dementia Acute myocardial infarction Congestive heart failure Stroke Surgical technique, n (%) Excision and direct closure Excision and flap Excision and graft Surgical complications, n (%) Wound infection Hemorrhagic complication Dehiscence Flap or graft necrosis Incompletely excised tumors, n (%)
≥80, n = 130
.99 4 (times)
3)
5)
4)
6)
Figure 1. (A) Cross-sectional association between glucose intolerance and instrumental activity of daily living (IADL) disability at baseline (N = 378). P < *.05, **0.01 using multiple logistic regression. (B) Longitudinal association between glucose intolerance and IADL decline over 5 years (n = 289). #P < .10 using multiple logistic regression. (C) Protective effect of participation of follow-up on IADL decline over 5 years in impaired glucose tolerance (IGT) and normal glucose tolerance (NGT) groups (n = 289). *P < .05 (NGT), †P < .05 (IGT) using multiple logistic regression. DM = diabetes mellitus.
P = .04), depression (OR = 2.77, 95% CI = 0.94–8.15, P = .06), age, sex, falling, and BMI (Figure 1B). All subjects were invited to participate in the five annual glucose intolerance and geriatric functional analyses and education about lifestyle modification during the 5-year study period.5,10 To analyze the preventive effect of followup participation of participants with NGT, IGT and DM on IADL decline, all subjects were assigned to one of two groups: more participation (≥4) or less participation (≤3). 1 NGT IADL 2 NGT IADL
with less participation (n = 108, 16.7% with decline). with more participation (n = 62, 14.5% with decline).
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
