12.
Espinosa V, Dutta O, McElrath C, et  al. Type III
interferon is a critical regulator of innate antifungal
immunity. Sci Immunol 2017; 2:pii:eaan5357.
Correspondence: D. P. Kontoyiannis, Department of Infectious
Diseases, University of Texas MD Anderson Cancer Center,
Houston, TX 77030 (dkontoyi@mdanderson.org).
Clinical Infectious Diseases®  2018;67(1):157–9
© 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.
DOI: 10.1093/cid/ciy039
Infection Control and What to
Wear in the Operating Room
To the Editor—Infection control prac-
tices concerning attire and behavior are
often a source for debate between oper-
ating and anesthesia staff and between
nurses and physicians. Fortunately, this
debate takes place over the head of the
sleeping patient. Bartek et al [1] add fuel
to the debate by repeating what is so often
said in the operating room. The article
does not add any new information to the
subject and is not a systematic review. We
are surprised it does not refer to the excel-
lent chapter titled “Safe Surgery” in the
World Health Organization document [2].
As far as we understand, the senior author
of “Naked Surgeons” is one of the contrib-
utors to this chapter, which has a very use-
ful list of references. An older review by
Hambraeus and Laurell [3] gives a historic
perspective on the subject. We comment
here on some specifics focused on in the
article by Bartek et al [1].
First, the use of operating room attire
is not likely to reduce surgical site infec-
tions in general abdominal surgery, where
the patients’ intestinal flora is the main
source of infection. There are situations
where evidence is not easily proved or
even necessary [4]. To look for evidence
that operating room attire (eg, gowns
and drapes) decreases the incidence of
surgical site infections in abdominal gen-
eral surgery would be waste of time and
money. The attire should be, and is, used
for practical reasons (eg, to protect the
operating team and contain fluid to pre-
vent spillage to footwear and the floor). If
this is stated, there might be less contro-
versy about what to use and when.
Masks prevent droplets containing
bacteria from the upper respiratory tract
from falling into the operating wound,
which is regarded as a direct route of
infection, not an airborne infection.
Bacteria from saliva are seldom the cause
of infection in the tissue operated on in
general surgery. Thus, masks are used
merely to protect the operating team.
Airborne infection is not a risk for gen-
eral surgical procedures unless there are
high air counts of Staphylococcus aureus
or Group A Streptococci owing to the
presence of a disperser of these bacteria
or a breakdown of the ventilation [5]. We
can comfort the authors with the fact that
excellent scrub suits—so-called clean air
suits—are now available to prevent skin
scales from reaching reach the air in the
operating room, if this is judged neces-
sary (eg, in orthopedic implant surgery),
but this is a totally irrelevant measure in
the context of general surgery.
Anna Hambraeus and Birgitta Lytsy
Department of Medical Sciences, Uppsala University,
Sweden
Notes
Acknowledgments. None.
Supplement sponsorship. None.
Financial support. None.
Potential conflicts of interest.  All authors:
No reported conflicts of interest.
References
1. 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.
2. World Health Organization. Safe surgery: why safe
surgery is important. 2009. Available at: www.who.
int/patientsafety/safesurgery/en/.
3. Hambraeus A, Laurell G. Protection of the patient
in the operating suite. J Hosp Infect 1980; 1:15–30.
4. Smith GC, Pell JP. Parachute use to prevent death
and major trauma related to gravitational chal-
lenge: systematic review of randomised controlled
trials. BMJ 2003; 327:1459–61.
5. Kundsin RB. Documentation of airborne infec-
tion during surgery. Ann N Y Acad Sci 1980;
353:255–61.
Correspondence: Birgitta Lytsy, Department of Clinical
Microbiology and Infection Control, Uppsala University
Hospital, SE-75185 Sweden (birgitta.lytsy@akademiska.se).
Clinical Infectious Diseases®  2018;67(1):159
© 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.
DOI: 10.1093/cid/ciy059
CORRESPONDENCE • CID 2018:67 (1 July) • 159
Reply to Hambraeus and Lytsy
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 sup-
ported demands regarding attire in the
OR [3, 4], which were subsequently turned
Downloaded from https://academic.oup.com/cid/article-abstract/67/1/159/4820998 by PYEONGTAEK UNIVERSITY user on 22 July 2020
into regulations by some organizations.
Hambraeus and Lytsy express surprise
C
that the World Health Organization chap-
ter 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 surgi-
cal 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 C
Assessment, Development, and Evaluation
(GRADE) system of rating quality of evi-
dence criteria, there are no recommenda-
tions 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 rou-
tine 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