TY - JOUR
AU - Dellinger, E Patchen
AB - To the Editor—We thank Hambr aeus and Lytsy [1] for their interest in our lighthearted review of what to wear in the operating room (OR) [2]. As noted in our piece, we became interested in this after some rather dogmatic and poorly supported demands regarding attire in the OR [3, 4], which were subsequently turned into regulations by some organizations. Hambraeus and Lytsy express surprise that the World Health Organization chapter on safe surgery [5], of which one of us is a coauthor, was not referenced. However, that excellent chapter does not refer to this topic beyond a brief comment stating that “masks that cover the mouth and nose, hair-coverings such as caps, sterile surgical robes and impermeable sterile gloves is standard for surgical teams” [5]. It goes on to note that “scientific evidence of their impact in preventing surgical site infections is not available or has been disputed” [5]. There is a newer report from the World Health Organization [6], of which one of us is also a coauthor and which was cited in our article, and in this new report, guided by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of rating quality of evidence criteria, there are no recommendations regarding use of masks or types of hats, scrubs, or gowns, essentially owing to lack of evidence on these topics. We agree with Hambraeus and Lytsy on the practical aspects of traditional OR attire for protecting the OR team as much as the patient. At least one of us has been wearing surgical masks, gowns, and hats on a routine basis since 1969, despite the absence of any evidence for their benefit to the patient, and as far as we know, none of us has been observed operating in the nude, although an article by Benediktsdóttir and Hambraeus [7] demonstrates that that would reduce airborne bacteria. We do, however, object to excessively arbitrary and dogmatic demands on attire that are unsupported by evidence or logic. When it comes to the theoretical association of airborne bacteria with infection, we note that the references by Kundsin [8] and Hambraeus [9] cited in the letter do not support the use of masks or an association of airborne bacteria with surgical site infections (SSIs) and do not mention head gear, and this was also noted in 2 other publications [10, 11]. The use of ultraviolet light to reduce airborne bacteria and thus SSI did not turn out to be effective [12], and laminar air flow has also been a disappointment, being associated with higher rather than lower SSI rates [13]. As far as headgear goes, the most recent articles available on this topic show greater airborne bacteria in an experimental setting for bouffant hats [14], and a recent large study showed a statistically nonsignificant increase in SSI rates in clean cases with the introduction of bouffant hats [15]. We also agree with. Hambraeus and Lytsy that there are some situations where level 1 or strong GRADE evidence is not required [16]. In our practices when patients ask what physical activities are allowed after a surgical procedure, we routinely advise against jumping from an airplane without a parachute. Notes Financial support. This work is supported by the National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health (training grant T32DK070555 to M. B. and F. V.). Disclaimer. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. References 1. Hambraeus A , Lytsy B . Infection control and what to wear in the operating room . Clin Infect Dis 2018 ; 67 : 159 . 2. Bartek M , Verdial F , Dellinger EP . Naked surgeons? The debate about what to wear in the operating room . Clin Infect Dis 2017 ; 65 : 1589 – 92 . Google Scholar CrossRef Search ADS PubMed 3. Burlingame B , Denholm B , Link T et al. Guideline for surgical attire. In: R Conner, ed. Guidelines for perioperative practice. Denver, CO: Association of periOperative Registered Nurses; 2017. 4. Spruce L . Back to basics: preventing surgical site infections . AORN J 2014 ; 99 : 600 – 8 ; quiz 609–11. Google Scholar CrossRef Search ADS PubMed 5. World Health Organization . WHO guidelines for safe surgery 2009 . Geneva, Switzerland : World Health Organization , 2009 . 6. World Health Organization . Global guidelines for the prevention of surgical site infection . Geneva, Switzerland : World Health Organization , 2016 . 7. Benediktsdóttir E , Hambraeus A . Dispersal of non-sporeforming anaerobic bacteria from the skin . J Hyg (Lond) 1982 ; 88 : 487 – 500 . Google Scholar CrossRef Search ADS PubMed 8. Kundsin RB . Documentation of airborne infection during surgery . Ann N Y Acad Sci 1980 ; 353 : 255 – 61 . Google Scholar CrossRef Search ADS PubMed 9. Hambraeus A , Laurell G . Protection of the patient in the operating suite . J Hosp Infect 1980 ; 1 : 15 – 30 . Google Scholar CrossRef Search ADS PubMed 10. Tammelin A , Hambraeus A , Ståhle E . Source and route of methicillin-resistant Staphylococcus epidermidis transmitted to the surgical wound during cardio-thoracic surgery: possibility of preventing wound contamination by use of special scrub suits . J Hosp Infect 2001 ; 47 : 266 – 76 . Google Scholar CrossRef Search ADS PubMed 11. Tammelin A , Hambraeus A , Ståhle E . Routes and sources of Staphylococcus aureus transmitted to the surgical wound during cardiothoracic surgery: possibility of preventing wound contamination by use of special scrub suits . Infect Control Hosp Epidemiol 2001 ; 22 : 338 – 46 . Google Scholar CrossRef Search ADS PubMed 12. Howard JM , Barker WF , Culbertson W et al. Postoperative wound infections: the influence of ultraviolet irradiation on the operating room and of various other factors . Ann Surg 1964 ; 160 : 1 – 196 . Google Scholar CrossRef Search ADS 13. Gastmeier P , Breier AC , Brandt C . Influence of laminar airflow on prosthetic joint infections: a systematic review . J Hosp Infect 2012 ; 81 : 73 – 8 . Google Scholar CrossRef Search ADS PubMed 14. Markel TA , Gormley T , Greeley D et al. Hats off: a study of different operating room headgear assessed by environmental quality indicators . J Am Coll Surg 2017 ; 225 : 573 – 81 . Google Scholar CrossRef Search ADS PubMed 15. Shallwani H , Shakir H , Aldridge A , Donovan M , Levy E , Gibbons K . Mandatory change from surgical skull caps to bouffant caps among operating room personnel does not reduce surgical site infections in class I surgical cases: a single-center experience with more than 15,000 patients . Neurosurgery 2017 : 1 – 7 . 16. Smith GC , Pell JP . Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials . BMJ 2003 ; 327 : 1459 – 61 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
TI - Reply to Hambraeus and Lytsy
JF - Clinical Infectious Diseases
DO - 10.1093/cid/ciy061
DA - 2018-01-23
UR - https://www.deepdyve.com/lp/oxford-university-press/reply-to-hambraeus-and-lytsy-1vMlPjLY3U
SP - 1
EP - 160
VL - Advance Article
IS - 1
DP - DeepDyve
ER -