COLLECTIVE REVIEW

Debunking the Myth: What You Really Need

to Know about Clothing, Electronic Devices,
and Surgical Site Infection
Wendy Jo Svetanoff, MD, MPH, Charlene Dekonenko, MD, Kayla B Briggs, MD, Joseph A Sujka, MD,
Obiyo Osuchukwu, MD, MPH, Robert M Dorman, MD, Tolulope A Oyetunji, MD, MPH, FACS,
Shawn D St Peter, MD, FACS

Surgical site infections (SSIs) comprise 20% to 33% of Recommendations, Assessment, Development, and Eval-
the total cost for hospital-acquired infections, and can uation (GRADE) approach to determine evidence-based
range from erythema requiring antibiotics to necrotizing recommendations on the relationship between different
infections requiring multiple trips to the operating aspects of surgical attire and surgical site infections.5-7
room.1,2 SSIs have also been shown to increase length of
stay by up to 10 days for certain high-level cases compared
with lengths of stay for patients who do not have an SSI.1 METHODS
Due to the assumption that these are potentially prevent- Study search
able, SSIs have become a focus of quality improvement
The initial literature review included all of the articles
projects in the surgical realm, and are among the major
included in the 2015 and 2019 “AORN Facility Refer-
outcomes assessed in the American College of
ence Center Guidelines for Perioperative Practice: Surgi-
SurgeonseNational Surgical Quality Improvement Pro-
cal Attire” documents.5,6 This literature search was then
gram (ACS-NSQIP) pediatric database.3 Typical areas
supplemented with a systematic literature search of
of focus in many institutional bundles include preopera-
PubMed, Ovid Embase, EBSCO CINAHL, and
tive factors, such as preoperative bathing and smoking
Cochrane Central databases, along with the grey litera-
cessation; perioperative factors, such as appropriately
ture, for relevant articles published between 2000
timed antibiotics an adequate skin preparation; and intra-
and 2019.
operative variables including maintaining normothermia,
The search was performed with the help of a university
blood glucose control, and patient factors. All of these
librarian. Key search words included “surgical attire” OR
have been shown to influence outcomes.1,4 However, the
“protective clothing” AND “upper extremity” for ques-
evidence regarding specific aspects of surgical attire
tion #1, “fomites,” “electronics,” “cell phones,” and “mi-
contributing to surgical site infections is less convincing.
crocomputers” for question #2, “surgical attire” OR
Our aim was to perform a systematic literature search,
“protective clothing” for question #3, “surgical attire
including articles referenced in both the 2015 and 2019
OR masks OR protective clothing” AND “Head OR
Association of periOperative Registered Nurses (AORN)
Hair OR neck” for question #4, “Laundry Service, Hospi-
Facility Reference Center Guidelines along with adding
tal” OR “Laundering” AND “Hospitals” for question #5,
additional published literature, and grade the quality of
and “Bacterial Shedding, “Dandruff” OR “Dander,”
evidence in these articles using a Grading of
“Skin,” “Hair” for question #6. The full list of search
terms used in each database search separated by search
question can be found in eDocuments 1e6.
Disclosure Information: Nothing to disclose.
The Guidelines were separated into 6 categories to
Received October 14, 2020; Revised November 10, 2020; Accepted answer the following questions:
November 11, 2020.
From the Department of General and Thoracic Surgery, Children’s Mercy 1. Does complete coverage of the arms of perioperative
Hospital (Svetanoff, Dekonenko, Briggs, Osuchukwu, Dorman, Oyetunji, team members, both scrubbed and nonscrubbed,
St Peter) and the University of Missouri-Kansas City (UMKC) School of
Medicine (Oyetunji, St Peter), Kansas City, MO; the Department of Gen- decrease surgical site infections?
eral Surgery, Tampa General Hospital, Tampa, FL (Sujka); and the Depart- 2. Does disinfection of electronic devices in the perioper-
ment of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, ative (operating room) setting decrease surgical site in-
OH (Dorman).
Correspondence address: Shawn D St Peter, MD, FACS, Department of
fections in patients?
General and Thoracic Surgery, Children’s Mercy Hospital, 2401 Gillham 3. Does full gown use by perioperative personnel decrease
Rd, Kansas City, MO 64108. email: sstpeter@cmh.edu surgical site infections?

ª 2021 by the American College of Surgeons. Published by Elsevier Inc. https://doi.org/10.1016/j.jamcollsurg.2020.11.032

All rights reserved. 320 ISSN 1072-7515/21
Vol. 232, No. 3, March 2021
Abbreviations and Acronyms
AORN ¼ Association of periOperative Registered Nurses
CHG ¼ chlorhexidine gluconate
CPG ¼ clinical practice guidelines
GRADE ¼ Grading of Recommendations, Assessment,
Development, and Evaluation
SSI ¼ surgical site infection
4. Does complete coverage of the head, including hair,
eyes, facial hair (sideburns), and nape of the neck by
a clean surgical head cover by perioperative team
members (in semi-restricted and restricted areas)
decrease surgical site infections?
5. Does surgical site infection decrease if perioperative
personnel change into street clothes when leaving the
building, and/or leave reusable scrub attire and reus-
able head covers at healthcare facilities for laundering
onsite?
6. Does shedding of the skin and hair from perioperative
personnel increase surgical site infections?
Study selection
Inclusion criteria included any study that was published
in English between 2000 and 2019, which addressed 1
of the 6 questions listed above. All articles obtained
were placed into Rayyan (Qatar Computed Research
Institute). The abstracts of all articles were reviewed for
inclusion criteria by 4 authors: (WJS, CD, KD, and
JS). Those articles kept after the initial exclusion process
were then read in full for possible inclusion using criteria
based on the GRADE algorithm (Fig. 1). Each article was
given a grade based on the appropriate level of evidence
each specific study provided. A fourth, and sometimes
fifth, reviewer (OO, TAO) were used to solve any discrep-
ancies that occurred during the grading process. Articles
that met all inclusion criteria were included in the final
analysis.
Analysis corp
The total number of articles and appropriate levels of ev-
idence grading were reviewed and separated based on
study question. Comparison of the AORN Guidelines
Recommendation and the levels of evidence were
completed.
Guideline #1: Does complete coverage of the arms
of perioperative team members, both scrubbed and
nonscrubbed, decrease surgical site infections?
Thirteen articles were identified that looked at a combina-
tion of scrubbing, gloving, and the gown-glove interface.
Svetanoff et al Surgical Attire and Surgical Site Infection 321
One article was a historical commentary that was
excluded. Another article was a systematic review that
addressed the quality of the clinical practice guidelines
instead of the relationship between the guidelines and sur-
gical site infections.8 Of the 13 articles, 9 were used as part
of our systematic review. Broken down by levels of evi-
dence, there were 2 level I, 2 level II, 2 level III, 1 level
IV, and 2 level V articles.
One prospective, randomized control trial, given level I
evidence, compared wound complication rates, including
infection, hematoma, or other complications requiring
treatment, after cesarean section.9 Physicians were ran-
domized to either changing gloves after delivery and
before abdominal closure or not changing gloves. The
study was appropriately powered to detect an improve-
ment in wound complication rates ranging between 9%
and 17%. The authors found a significant decrease,
from 13.6% to 6.4% (p ¼ 0.008), when physicians
changed gloves after delivery and before abdominal
closure.9 In a systematic review by Tanner and Parkin-
son,10 multiple studies were able to show that double
gloving or use of a colored under-glove led to fewer per-
forations of the inner-most glove compared to a single
glove, and were able to detect perforations during the
operation with a greater accuracy compared to the use
of a single glove only. However, only 2 studies in the sys-
tematic review looked at the relationship between glove
perforation and surgical site infection and found there
was no difference in the rate of surgical site infections,
although the total cohort sizes were small.10
Likewise, 1 level II study compared the incidence of ce-
rebrospinal fluid shunt infections between a cohort in
which the surgeons replaced their outer layer of gloves
before handling the shunt material vs a group that did
not.11 The results from this study did not show a signifi-
cant reduction in the rate of shunt infection between
groups; however, the patient population was heteroge-
neous, with some patients requiring a cerebrospinal fluid
shunt for subarachnoid hemorrhage or for normal pres-
sure hydrocephalus. Another confounding factor was
that patients undergoing an initial shunt placement and
those who had previous shunt revisions were included.11
On multivariate analysis, which accounted for these con-
founders, intraoperative glove change led to a decrease in
postoperative shunt infection rates only in patients who
were receiving their first shunt.11
Other level II studies looked at bacterial counts. A
study by Kozon and colleagues12 measured the bacterial
count on surgeon’s gloves and the assistant’s gloves before
handling a pacemaker for implantation. The wound in
which the pacemaker was placed was also cultured.12 In
67% of cases, there was contamination of either the
322 Svetanoff et al Surgical Attire and Surgical Site Infection
Figure 1. Grading of Recommendations Assessment, Development
and Evaluation (GRADE) algorithm for determining levels of evidence
of scientific manuscripts.
surgeon’s or the assistant’s gloves, with 42% of cases also
having wound contamination. Interestingly though, no
patients developed a clinical infection, either at 30 days
postoperatively or within the first 2 years after pacemaker
implantation.12 A study by Markel and colleagues13 per-
formed a mock prepping experience with the participants
either in a long-sleeve gown and gloves or with uncovered
arms. While there was decrease in Micrococcus seen, there
was no overall difference in bacterial contamination,
either with the use of a gown and gloves or when perform-
ing a surgical prep with exposed arms.13 As this was per-
formed in a mock patient room, it is unclear how this
would relate to potential surgical site infections, as the pa-
tient’s individual flora can also play a role in SSIs and is
the reason for cutting of hair and baths with chlorohexi-
dine cloths before the operative procedure.
Finally, in a randomized crossover design of level II ev-
idence, 25 operating room personnel were asked to scrub
for 2 or 3 minutes. Surgical gloves were placed, and the
personnel proceeded to continue with their normal
work tasks for 1 hour.14 Bacterial counts on the hands
and the evidence of glove perforation were assessed. To
complete the crossover portion of the trial, each partici-
pant scrubbed for the alternating amount of time approx-
imately 1 week later and bacterial counts were obtained.
There was no difference in the bacterial count found on
J Am Coll Surg
the hands of the participants after scrubbing for either 2
or 3 minutes before donning surgical gloves.14 There
was no patient care performed in this study, and therefore,
no interpretation about how this affects patient safety in
terms of surgical site infections could be performed.
The AORN Guidelines make a conditional recommen-
dation to cover the arms during the performance of pre-
operative patient skin antisepsis; however, there is no
evidence to show that this decreases SSIs.6 Therefore,
for procedures that lead to visible soilage of bowel or
intra-abdominal contents (ie cesarean section) on the
gloves, surgical gloves should be replaced before closure
of the abdominal cavity to decrease the incidence of sur-
gical site infections. There are no data on the use of single
or double gloves to prevent surgical site infections; how-
ever, the use of double gloves should be considered
when operating on high-risk patients for the protection
of the provider.
Guideline #2: Does disinfection of electronic de-
vices in the perioperative operating room setting
decrease surgical site infections in patients?
Eleven articles looked at the use of electronic devices and
their association with surgical site infection. The articles
consisted of 1 level II, 1 level III, 4 level IV, and 5 level
V articles. In a review article, both pathogenic and
nonpathogenic bacteria were reported to be colonized
on handheld electronic devices.15 Alcohol wipes reduced
contamination by 79%, and when used daily, alcohol
wipes prevented the colonization of pathogenic bacteria
on the devices. However, there have been no data to
link device contamination to infections in patients or de-
vice owners.15 Similarly, in a literature review by Brady,16
a 9% to 15% contamination rate of mobile devices with
pathogenic bacteria was documented.16 “Pathogenic” bac-
teria were defined as strains associated with clinical infec-
tions. While 3 studies in the review found that bacteria
found on mobile devices could be transmitted to the
hands of the healthcare worker, no article directly looked
at the amount of contamination or bacterial count on the
electronic device and the incidence of surgical site infec-
tion. Two case reports described the use of a sterile phone
camera17 or iPad,18 but no outcomes, in terms of surgical
site infections, were reported. Six articles focused on the
bacterial count of electronic devices; however, it is unclear
what bacterial count level is associated with adverse out-
comes because the incidence of surgical site infections
was not reported.15,19-23
The AORN Guidelines recommend that electronic de-
vices should be cleaned before entrance into the operating
room.6 Personal items, such as backpacks or briefcases, are
either restricted from use or must be cleaned before
Vol. 232, No. 3, March 2021 Svetanoff et al
operating room entrance (conditional recommendation).
Based on the lack of evidence, the current recommenda-
tions cannot be supported; however, if one wishes to limit
the contamination of mobile cellular devices, cleansing
with alcohol wipes should be performed at a minimum
of every 48 hours.
Guideline #3: Does full gown use by perioperative
personnel decrease surgical site infections?
Fifty-nine articles were found concerning the contamina-
tion of scrubs and gowns, the glove-gown interface, and
the use of shoe covers or other surgical attire to prevent
infection. Four articles were either current guidelines or
updates to previously published guidelines.24-27 There
were 2 level I, 10 level II, 7 level III, 11 level IV, and
15 level V articles. In the articles providing level I or II
evidence, studies could further be grouped into 2 cate-
gories: evaluation of contamination of surgical gowns
and attire in the operating room, and analysis of contam-
ination of scrubs on healthcare workers in the ICU.
The first study to look at the role gowns and drapes
played in the rate of intraoperative wound contamination
occurred in 1986.28 A blinded prospective, randomized
trial compared gowns and drapes that were made with
reusable woven cotton and polyester fibers with disposable
nonwoven fiber and polyester blend. Only clean cases
were included in the study. No difference was found in
the rate of wound contamination (25% vs 30%) or clin-
ical wound infections (2.2% vs 2.2%) between groups.28
The strength of this study lies in the follow-up of patients
to determine if there was a difference in the rate of clinical
wound infections, which was unseen in other studies.
Robust studies focused on operating room attire found
that the use of jackets had no influence on SSI rates. A
propensity-matched study, providing level II evidence,
evaluated the implementation of the 2015 AORN oper-
ating room attire guidelines on the rate of surgical site in-
fections and cost within 1 institution.29 Patients who
underwent either inpatient or outpatient surgery before
implementation of the 2015 AORN guidelines, were
matched to patients who underwent surgery after imple-
mentation of the guidelines. Specific areas of the guide-
lines were addressed, including the use of long-sleeve
jackets in semi-restricted areas, nondisposable caps should
be covered by a disposable head covering, and scrub attire
that covers the arms should be worn while prepping the
patient before surgical intervention. For the propensity
analysis, patients were matched based on BMI, comorbid
conditions, duration of procedure, the emergent nature of
the procedure, and preoperative wound classificationeall
risk factors known to influence the rate of surgical site in-
fections. No difference was found in SSI rates between
Surgical Attire and Surgical Site Infection 323
those who had surgery before implementation of the
AORN guidelines and those who underwent surgery after
implementation.29 The operating room attire policy was
not associated with a decrease in SSIs, and there was
even a trend toward a higher rate of intra-abdominal ab-
scesses after the policy change (19.7% vs 29.4%, p ¼
0.07). On multivariate analysis, factors that were associ-
ated with increased infection rates included age greater
than 75 years, diabetes, a procedure longer than 3 hours,
emergent procedure, and wound classification; long-sleeve
jackets and nondisposable caps did not affect SSI rates.
Another study analyzed 6,517 patients in the American
College of Surgeons National Surgical Quality Improve-
ment Program (NSQIP) database.30 The rate of surgical
site infections among patients who underwent surgery at
2 hospitals in the 9 months preceding implementation
of the AORN operating room attire guidelines were
compared with those for patients who underwent surgery
in the 9 months after AORN guideline implementation.30
While propensity-matching was not used in this analysis,
a univariate screen was performed, with all variables hav-
ing a value of p < 0.20 used in a multivariable analysis.
On univariate screen, there was no difference in rates of
total SSIs, incisional SSIs, or organ-space infections,
which was confirmed on multivariable analysis. Factors
that did influence the rate of SSIs included preoperative
wound infection, open wound preoperatively, morbid
obesity, operating time > 75th percentile, and wound clas-
sification of dirty or contaminated.30 Interestingly, in a
comparison of the 2 hospitals in this study, hospital 1
had stricter policies regarding the adherence to the
AORN attire guidelines. When focusing on clean and
clean-contaminated procedures, the odds ratio of devel-
oping an SSI was 2.6 times higher compared with that
in hospital 2.30
A multi-institutional survey analyzed adherence pat-
terns to 38 infection control practices that were known
or were believed to influence the rate of surgical site infec-
tions.31 Survey questions ranged from inquiring about
operative attire (were scrubs worn outside the hospital,
use of cloth scrub caps, use of shoe covers, etc), patient
preparation (preoperative chlorhexidine gluconate
[CHG] bathing, clippers for hair removal), intraoperative
measures (maintain euglycemia and euthermia, changing
of gloves and instruments for wound closure), prophylac-
tic antibiotic use, and postoperative care. Results pertain-
ing to operating room attire from the 21 hospitals
surveyed found that 17 reported that surgeons wore
scrubs outside the operating room 76% to 100% of the
time, up to 50% of surgeons and up to 75% of anesthe-
siologists wore personal cloth scrub caps, up to 50% of
surgeons brought uncovered bags into the OR, and
324 Svetanoff et al Surgical Attire and Surgical Site Infection
51% to 75% of operating room personnel wore covered
forearms.31 No correlation was found between any of
the operative attire practices identified and surgical site
infection rates. Factors that were found to be significant
were the use of a preoperative CHG bath, skin prepara-
tion with CHG or alcohol-based product, and use of
clean gloves and instruments before wound closure.31
The use of body exhaust suits in order to decrease the
risk of wound infections in patients undergoing total joint
replacement is another area that was frequently studied. A
British randomized, prospective trial compared the bacte-
rial counts during knee replacement after the use of body-
exhaust suits vs occlusive clothing.32 While the bacterial
count of the air was significantly less with the use of a
body-exhaust suit, there was no difference in the bacterial
count of the wound, no difference in the percentage of
wounds in which bacteria were recovered, and no correla-
tion between air and wound bacterial counts.32 No further
analysis was performed to determine if there was a differ-
ence in clinical infections. Another British study random-
ized surgeons performing hip or knee replacements
wearing Rotecno gowns (hydrophobic, polyester material)
or Gore liquid-proof fabric gowns.33 The Gore gowns
were found to be associated with higher air bacterial
counts than the Rotecno gowns; however, clinical infec-
tion rates were not assessed as part of the study, so it is
unclear whether this translated to a higher rate of surgical
site and prosthetic joint infections.
In an ICU study evaluating scrub contamination (level
II evidence), 3 arms were randomized with crossover.
Standard, silver impregnated and ammonium/fluoroacry-
late impregnated scrubs were compared.34 Nurses working
in the ICU were randomized to wear 1 of the 3 separate
scrubs on 3 consecutive shifts. There was no difference in
contamination rates between the 3 pairs of scrubs.
Furthermore, while 16% of clothing was found to be
contaminated with Staphylococcus aureus or multidrug-
resistant bacteria, these were all found to be transmitted
from patients who already had the offending organism;
the study did not analyze if this acquisition of bacteria
on the clothing led to new infections among the pa-
tients.34 Another ICU-based randomized-crossover study
providing level II evidence compared bacterial contamina-
tion of scrubs that were treated with an antimicrobial
coating vs standard scrubs.35 Healthcare workers received
2 sets of each type of scrubs and were given a random
generated sequence in which order to wear the scrubs.
Thirty percent of all scrubs were found to have bacterial
contamination with either Staphylococcus aureus, Entero-
coccus species, or gram-negative bacteria, and there was
no difference between groups in the rate of contamina-
tion, type of species isolated, or in total bacterial count.35
J Am Coll Surg
It is unclear whether there is any correlation between the
contamination rate and incidence of hospital-acquired in-
fections among the patient population being cared for by
the healthcare groups. The use of silver-impregnated
scrubs was also studied in a veterinary hospital.36 While
silver-impregnated scrubs had a significantly lower bacte-
rial count at the start of the shift, no difference in bacterial
count was found between the silver-impregnated and
standard scrubs after 4 hours and 8 hours of use.36
Finally, a randomized controlled trial from the Univer-
sity of Maryland compared surfaces in intensive care
rooms that were frequently touched by healthcare
workers. These surfaces were subjected to either standard
cleaning or 1 extra cleaning of all frequently used sur-
faces.37 Patients in all rooms were known to either have
methicillin resistant Staphylococcus aureus (MRSA) or
multidrug resistant Acinetobacter baumannii (MDRAB).
A significantly higher percentage of surfaces on which
an extra cleaning was performed were found to be clean
using fluorescent gel markers compared to surfaces that
were subjected to standard cleaning only (100% vs
26%, p < 0.001). Despite this difference, the percentage
of used gowns and gloves that were found to be contam-
inated were similar between groups in both the MRSA
and MDRAB cohorts.37 No further analysis looking at
the rates of newly acquired patient infections was per-
formed, so how these decreases in bacterial counts or
improved cleanliness relate to patient infections is
unknown.
In summary, from the data available directly comparing
operative attire practices and surgical site infections, no
correlation was found. While many studies have focused
on the bacterial count found with the use of certain types
of impregnated scrub material or body-exhaust suits,
propensity-matched, multivariate, and multi-
institutional studies that specifically addressed SSI rates
found no correlation between surgical attire practices
and the incidence of SSIs.
Guideline #4: The use of masks and head coverings
in the operating room
Articles concerning the use of masks, beards, and head
coverings were the second most common topic found in
the systematic literature review with more robust data.
Twenty articles were found pertaining to the use of masks,
with 4 level I, 3 level II, 2 level III, 1 level IV, and 10 level
V articles identified. Nine articles were found comparing
head coverings, with no level I, 5 level II, 1 level III, no
level IV, and 3 level V articles identified.
Concerning the use of masks, a systematic review pub-
lished in 2001 found 29 articles, of which 2 were random-
ized trials. There was no difference in rates of surgical site
Vol. 232, No. 3, March 2021 Svetanoff et al
infections between a masked surgical team and an
unmasked surgical team. In 1 prospective trial and 1 ran-
domized trial, the raw infection rate of patients in the
nonmasked group was lower than in the masked group,
although this was not statistically significant.38,39 A later
systematic review with level I evidence found few addi-
tional studies looking at the use of masks in the operating
room and the incidence of surgical site infections.40 Only
3 studies met inclusion criteria. In 1, a systematic review,
and in another, a prospective trial with a historical control
group, there were no differences in the rates of surgical
site infections, whether the entire operating team wore a
mask or not.40 One randomized study was stopped early,
after 3 wound infections were found in the group in
which no masks were worn by the surgical team during
the procedure. However, the power of the study was
low, it was stopped early, and no clear definition of a
wound infection was given.40
A Cochrane systematic review with meta-analysis
looked at randomized and quasi-randomized controlled
trials to further elucidate if the use of masks by either
the surgical team or the nonscrubbed staff during clean
surgical procedures played a role in surgical site infec-
tions.41 A total of 2,106 study participants were analyzed,
and no difference in the rate of wound infections after
clean surgical procedures was found between the group
in which disposable surgical masks were worn and the
group in which no surgical masks were worn.41 Updates
to this Cochrane systematic review and meta-analysis in
2014 and 2016 found that no new studies that fit inclu-
sion criteria had been published; therefore, there was no
change in the study’s findings that there was no evidence
that the use of disposable surgical masks affects the likeli-
hood of developing a surgical wound infection after
surgery.42,43
This lack of difference among providers who did and
did not wear masks was reported in additional studies spe-
cifically focusing on the use of masks during cardiac cath-
eterizations. The findings of these studies are
contradictory, as they showed opposing results when
examining the incidence of bacterial shedding.38,44 An
important note, however, is that while there was a higher
rate of bacterial shedding, no correlation could be made
to the incidence of SSIs. While surgical masks are thought
to protect the patient from bacteria emitting from the sur-
gical team, masks are also thought to protect the surgical
team from bacteria the patients carry with them. Howev-
er, 1 study found that surgical masks were not efficient in
offering protection to staff from potentially hazardous
aerosolized particles.45
Finally, in a study looking at the incidence of bacterial
contamination after the clashing of surgical visors above
Surgical Attire and Surgical Site Infection 325
the operating field, higher bacterial counts were found
in the sham operative field (blood agar plates) than
when no clashes occurred.46 The surgical visors studied
consisted of a face mask with a clear visor that projected
upward to protect the eyes and upper face. Although sur-
gical knot tying practices were incorporated into the pro-
cedures to simulate real operative occurrences, these were
all sham procedures and therefore, it cannot be deter-
mined whether the bacterial contamination would trans-
late into a higher SSI rate or not.46 In conclusion, there
is no definitive evidence that the use of surgical masks
in the operating room decreases the incidence of surgical
site infections. Masks as personal protective equipment is
a separate issue and the value is dependent on patient and
procedure.
There were 2 articles that commented on beards; how-
ever, both articles analyzed only bacterial counts on agar
plates and were unable to make any correlation to poten-
tial surgical site infections. One article compared bacterial
shedding after wiggling the face while wearing a mask in
bearded males, clean-shaven males, and female patients.47
Both females and bearded males shed more bacteria than
clean-shaven males with mask wiggling, with the bearded
males shedding more particles at rest than either the
clean-shaven males or females.47 In contrast, in a more
recent article from 2016, orthopaedic surgeons were asked
to perform facial movements while a blood agar plate was
situated below the chin.48 This was done in an empty
room to minimize bacterial contamination. While all sur-
geons who were unmasked shed more particles, there was
no difference between the clean-shaven and bearded
groups while unmasked, masked, or wearing a mask
with a disposable surgical hood; there was also no differ-
ence between the bearded group when wearing either a
surgical mask with hood or a surgical mask alone.48 As
neither study was able to directly correlate these findings
to the incidence of surgical site infections, no recommen-
dation can be made on beard coverings.
Multiple studies evaluated the type of surgical hat used
and its relationship to SSIs. Using the Americas Hernia
Society Quality Collaborative database, surgeons were
sent a survey inquiring about the type of surgical cap
worn in the operating room before implementation of
the AORN guidelines in 2016.49 A disposable skull cap
was worn by 45.6% of surgeons, 29.4% wore a disposable
bouffant, and 9% wore a cloth skull cap. There was no
association on either univariate or multivariate analysis
between the type of surgical cap worn and an increased
incidence of surgical site infections or occurrences that
required a procedural intervention.49 Instead, a higher
modified Hernia Working Group grade of hernia, the
presence of drains, and an enterotomy were variables
326 Svetanoff et al Surgical Attire and Surgical Site Infection
found on multivariate analysis to be associated with an
increased risk of SSIs.
A retrospective subset analysis from a previously ran-
domized controlled trial compared the rate of surgical
site infections in surgeons who wore bouffant vs skull
caps.50 Approximately two-thirds of surgeons were found
to wear skull caps, although there was no mention if the
head coverings were disposable or cloth.50 Overall, the
incidence of surgical site infections was lower in the skull
cap group; however, after multivariable analysis that
controlled for type of operation and surgical approach,
no difference was found between groups.
Another study compared surgical site infection rates 13
months before a mandated ban on the use of surgical
scrub caps with 13 months after the policy change was
in place.51 More than 15,000 surgical procedures were
included in the analysis, and no difference was found in
both the cumulative rate of SSIs and the monthly rate
of SSIs between all surgical procedures, spinal procedures,
and neurosurgery/craniotomy procedures between the 2
groups.51 Corroborating these findings, another study
investigated surgical site infections identified from the in-
stitution’s NSQIP data in patients who underwent clean
and clean-contaminated procedures 12 months before
and 12 months after implementation of a policy change
preventing the use of skull caps in the operating room.52
There was no difference in overall incidence of surgical
site infections or association between implementation of
the new policy and decreased incidence of surgical site in-
fections on multivariable analysis.52 Similar to other
studies, no mention was made of use of disposable vs
cloth head coverings.
Using a mock surgical procedure, a laboratory study
compared airborne particulate and contaminant matter
as well as the permeability and ability for particle trans-
mission between disposable bouffant caps, disposable
skull caps, and cloth skull caps.2 Disposable bouffant
caps were found to have a significantly higher microbial
shed than either the disposable or cloth skull caps and
were also found to be significantly more permeable than
either type of skull cap. Airborne particle contamination
was also significantly higher in the bouffant group
compared to the cloth skull cap group.2 However, as par-
ticulate and microbial contamination was measured only
during sham operations, how this translates to surgical
site infections remains unclear.
In summary, multiple studies both looking at particu-
late count and surgical site infections found no difference
between providers who wore disposable bouffant caps,
disposable skull caps, or cloth skull caps. This finding
agrees with the AORN Guidelines, which could make
no recommendation for the most appropriate type of
J Am Coll Surg
head covering to be worn in restricted areas.6 Therefore,
the provider should have the option to choose the head
covering attire that is most comfortable for him/her.
Guideline #5: Are surgical site infections decreased
if perioperative personnel: A) change into street
clothes when leaving the building, or B) leave
reusable scrub attire and reusable head covers at
healthcare facilities for laundering onsite?
Twenty-two articles were found that focused on laun-
dering of scrubs or hospital clothing. Two articles were
guidelines published in the AORN Journal. Both of these
guidelines stated that the laundering of scrubs or hospital
clothing should be performed at a hospital facility.53,54 Of
the 18 studies, there were 0 level I, 2 level II, 1 level III, 4
grade IV, and 13 grade V articles.
One level 2 study was a review aimed at answering the
following questions: can scrubs act as a vehicle for trans-
ferring bacteria; is there a relationship between microbes
found on scrub uniforms and SSI; what are the differences
between facility laundering or home laundering in micro-
bial decontamination; and what are the current or sug-
gested recommendations for the decontamination of
surgical scrubs? While it was found that scrubs can act
as a vehicle for fomites, there was no association with
increased surgical site infections.55 Also, no compelling
evidence was found favoring facility-laundered scrubs vs
home-laundered scrubs. The recommendations therefore
included that laundering scrubs at home was safe if the
following guidelines were implemented: use water tem-
perature of at least 60oC, use bleach-based detergents,
use the highest dryer settings and iron scrubs immediately
after washing, launder scrubs in a separate cycle and as a
last load after all other laundry, disinfect the washer after
removing the scrubs, and protect the scrubs from reconta-
mination by securing them in closed bags and waiting un-
til arriving at work to put them on.55
The other level II study was a single-blinded random-
ized trial comparing bacterial burden of scrubs worn by
labor and delivery residents, with residents being assigned
to 1 of 4 groups: launder scrubs at home and dress at
home, launder scrubs at home but dress in the hospital,
launder scrubs in the hospital but dress at home, and
launder scrubs in the hospital and dress in the hospital.56
While 69% of scrubs were found to have at least some
bacterial growth on analysis, there was no difference be-
tween scrubs that were laundered at home vs in the hos-
pital or in home-dressed vs hospital-dressed cohorts.
There was also no difference in bacterial burden at the
beginning of a shift between the home-dressed and
hospital-dressed cohorts. No analysis was performed
Vol. 232, No. 3, March 2021 Svetanoff et al
looking at whether this bacterial count had an impact on
wound infections.
Finally, a randomized trial looking at bacterial contam-
ination of hospital mattresses with or without the use of a
launderable cover found that the use of a launderable
cover prevented any contamination of the mattress during
patient use.57 The launderable cover was also found to
have less contamination before patient use than the bed
mattress that was cleaned with disinfectant before patient
use.57 Due to lack of evidence and other possible contam-
inants found in the workplace that might contribute to
bacterial colonization on hospital attire, it is unknown
whether a direct correlation can be made between laun-
dering at home vs at a hospital facility and surgical site
infections.
The AORN Guidelines recommend that scrub attire
should be laundered at a healthcare accredited laundry fa-
cility, that surgical attire should be stored in enclosed carts
or dispensing machines, and that surgical attire should be
removed before leaving the healthcare facility.6 However,
due to the paucity of adequate data, no recommendations
can be made about any of these issues because there is no
evidence to show that this has any influence on SSI rates.
Guideline #6: Does shedding of skin from periop-
erative personnel increase surgical site infections?
Twenty-six articles were identified: 4 level I, 4 level II, 1
level III, 8 level IV, and 5 level V articles. Two articles
were excluded as they were summary of guidelines and
provided no new evidence. More specifically, topics in
this section focus on shedding from white coats, surgical
attire, and body exhaust suits.
A systematic review published in 2019 found 22 articles
(4 randomized controlled trials and 16 cross-sectional
studies) that addressed bacterial contamination of white
coats and scrubs.58 While both white coats and scrubs
were found to be contaminated with both drug-resistant
and nondrug-resistant organisms (Staphylococcus aureus,
coagulase-negative Staphylococcus, Acetinobacter spp,
MRSA), no direct link was found between contamination
of provider attire and hospital-association infections.58
The recommendations laid forth by the Centers for
Disease Control and Prevention were unable to comment
on the use of space suits/body exhaust suits as a means of
decreasing SSI rates.4 No other recommendations con-
cerning surgical attire or shedding and their relationship
to SSI rates were made from these guidelines. However,
consensus guidelines from the International Consensus
on Orthopedic Infections convened to discuss many
topics related to air flow and surgical site infections
rates.59 There was strong consensus that the use of laminar
flow operating rooms did not have an effect on surgical
Surgical Attire and Surgical Site Infection 327
site infections (SSIs) and prosthetic joint infections
(PJIs); however, there was no evidence that the use of
forced warmed air increased the risk of SSIs. The temper-
ature of the operating room did have an effect on core
body temperature and therefore, may have an effect on
SSIs/prosthetic joint infections. Subsequently, high qual-
ity evidence was found leading to a unanimous vote with
the strongest consensus, that the levels of airborne micro-
organisms were proportional to the incidence of pros-
thetic joint infections.59
Continuing to focus on the orthopaedic literature, a
randomized controlled trial of patients undergoing total
knee arthroplasty had surgeons wear either standard
gowns, positive pressure surgical helmet systems without
tape at the glove-gown interface, and surgical helmet sys-
tems in which the glove-gown interface was taped.60
Wound cultures were obtained to assess for wound
contamination. The authors found no difference in the
rate of wound contamination between groups, although
it is unclear if any contaminated wounds progressed to
a clinical surgical site or prosthetic joint infection.
In an experimental level II study, air contamination
near the wrist, chest, and feet was compared between sur-
geons who wore a standard surgical gown or a body
exhaust suit.61 There was no difference in air contamina-
tion at the level of the wrists or chest between the 2
groups. In both groups, the surgeon stepping side to
side increased the air contamination at the level of chest,
with those who wore the body exhaust suits having a 31-
fold increase in chest contamination with stepping
compared to not stepping.61 However, it is unknown if
the counts were performed during a real operation or a
sham/simulated procedure, and therefore, no data were
provided on how these increased air counts correlated
with surgical site infections.
Another level II study analyzed how different physical
movements that are performed in prepping and perform-
ing orthopaedic procedures, and specifically, total knee
arthroplasty, contribute to airborne particle counts.62 Pre-
paring the instrument table, gowning, and donning/
removing surgical gloves all produced similar airborne
particle counts; when prepping the leg for total knee
arthroplasty, placing the large drape or stockinet gener-
ated airborne particles that were able to be shifted away
from the operative field when laminar air flow was
used.62 Similar to other studies examining particle and mi-
crobial contamination of air, this experiment was done
with the use of a sham procedure; therefore, no inferences
can be made as to how these particle counts are associated
with surgical site infections.
There were no AORN Guidelines pertaining to the use
of body exhaust suits or surgical helmet systems, and from
328 Svetanoff et al Surgical Attire and Surgical Site Infection
the evidence, it remains unclear whether air flow or the
type of gown and/or helmet system used has any influence
on surgical site or joint infections for patients undergoing
prosthetic joint replacement.
DISCUSSION
Recommendations for the prevention of surgical site in-
fections from the Centers for Disease Control and Preven-
tion were published in 2017.4 Based on their systematic
review of the literature and GRADE approach to assess
the quality and strength of evidence, the following guide-
lines were recommended: patients should bathe with soap
or an antiseptic agent before the operation, antimicrobial
prophylaxis should be appropriately timed, skin prepara-
tion should be performed using an alcohol-based agent,
antibiotic prophylaxis should not be continued after
skin closure in clean and clean-contaminated cases,
normothermia and euglycemia should be maintained
throughout the operation, and transfusion of blood prod-
ucts should not be withheld as a means to prevent surgical
site infections if they are clinically indicated.4
These guidelines do not comment on the type of
clothing or gowns worn, the best head covering to use,
where to change into operating room attire, or whether
personal electronic devices can be brought into the oper-
ating room. Based on our review of the literature, we
believe this area is lacking because there is no evidence
that any of these practices correlate with differences in
surgical site infections. Yet, the guidelines that most often
dictate this area of surgeons’ lives are based off of inade-
quate or incomplete studies that provide little insight on
the impact to SSI rates. Multiple studies were found
that looked specifically at implementation of the AORN
Guidelines,29-31 and not only were the AORN Guidelines
not found to be associated with SSIs, but in 1 study, the
SSI rate increased after implementation of the 2015
AORN Guidelines.30
In seeking to produce a clinical practice guideline that
met the standards of the Agency for Healthcare Research
and Quality (AHRQ) and Institute of Medicine (IOM),
AORN guidelines followed the letters of the law, but sys-
tematically undermined the spirit of it. Evidence became
intertwined with hypotheses, and both were presented as
evidence. For example, in the AORN evidence rating
guide, no evidence is required to support a recommenda-
tion if the authors believed that benefits of an intervention
outweighed the harm.63 Likewise, experts can offer their
opinion on what recommendations should be made.
This means that there is no barrier beyond opinion that
is required to be included as a recommendation. Recom-
mendations were not included with a summary of the
J Am Coll Surg
level and quality of evidence or strength of recommenda-
tion, which is standard when developing guidelines. Level
and quality were combined arbitrarily into grouped evi-
dence ratings categorized as 1 (strong), 2 (high), 3 (mod-
erate), 4 (limited), and 5 (benefits balanced with harms).
The strong category includes A-quality consensus state-
ments, while the high category contains systematic reviews
of B-quality. The AORN evidence appraisal tool for non-
research does not include an assessment of the level or
quality of evidence in the consensus statement or practice
guideline being assessedeonly whether there was a rating
scheme used to determine quality of evidence. Further-
more, regulatory requirements are listed as an evidence
ratingethe highest, in fact, supplanting research and
opinion alikeewhich further conflates authority with
understanding.
The AORN guidelines also have little distinction be-
tween systematic reviews and unguided literature reviews.
While guidelines, statutes, and basic science studies estab-
lish the validity of individual facts (eg Summers and col-
leagues64 proving that hair harbors pathogenic bacteria)
are important references when laying out an argument,
the goal of the systematic review is to amass evidence sup-
porting the relative benefits and harms of a recommenda-
tion. A literature review could easily be run through a
clinical practice guidelines (CPG) process and appear to
represent evidence-based practice recommendations.
CPGs must use a systematic review objectively to assess
the existing evidence for a specific question. Hypotheses
that underlie the final recommendations in guidelines
are generated as all hypotheses areein an organic way
by experts experienced in their field and immersed in
the published and unpublished research of their col-
leagues. While short of a meta-analysis of existing ran-
domized trials, each hypothesis is essentially tested by a
systematic review of the literature.
The use of systematic reviews for CPGs, however,
should address the evidence for causality, treatment effect,
dose-response, and other elements of the testing hypoth-
esis through the scientific method. In the example above,
one might slide over the fact that the Summers and col-
leagues64 article is relevant to the discussion about head
covering, but not evidence for head covering, because it
does not address that question. It addresses, instead, the
question of whether hair harbors bacteria.64 One can
construct a strong mechanistic argument by proving
that the following are true: hair harbors bacteria; uncov-
ered hair sheds more bacteria; wounds contain more bac-
teria in environments with more airborne bacteria;
bacteria are known to cause wound infections (Fig. 2).
However, this does not constitute evidence supporting
the last step recommending that hair be covered in a
Vol. 232, No. 3, March 2021 Svetanoff et al Surgical Attire and Surgical Site Infection 329

Figure 2. Determining the relevance of a study based on the evidence it provides. The study performed
by Summers and coworkers,64 which looked at the bacterial count in hair vs the retrospective review by
Kothari and associates,50 highlights how direct evidence, with the primary outcome being the hypothesis
of interest, is required for accurate evidence-based guidelines to be conceived. SSI, surgical site
infection.

CPG. Instead, studies, such as that of Haskins and col-
leagues and Kothari and associates, address this question
directly, using multivariate analyses of established cohorts
in order to not only determine the association between
surgical site infections but to also control for confounding
factors already known to increase the SSI risk, such as sur-
gical approach or if an enterotomy was performed during
the procedure.49,50
There is danger when large political bodies issue state-
ments that may influence policies. It is critical that any
communication follow the evaluation of evidence with
the objective assessment of fact and experiment to prevent
statements that don the guise of science. These empty
statements without strong evidence, which are not
declared as such, may still influence national policy and
widespread change. The unsupported guidelines can be
declared evidence-based while relying on the opinions of
the others as evidence. This sets up the opportunity for
systematic amplification and elevation of opinion to
fact, all under the auspices of evidence-based medicine.
This is an insidious trend that must be rooted out by
the rigorous standards of evidentiary support of recom-
mendations. Otherwise, we will see further implementa-
tion and imposition of costly rules under the defense of
common sense. There is nothing wrong with stating un-
supported recommendations, as long they are
transparently declared as such with the appropriate grade
of recommendation.
CONCLUSIONS
Minimal studies exist to adequately provide evidence-
based guidelines on the surgical attire of nurses, surgeons,
and anesthesiologists to make any recommendations on
how to best prevent surgical site infections. Further ran-
domized control trials or cohort studies with the inci-
dence of SSIs as a primary endpoint are needed for
evidence-based guidelines to be formulated. Given the
current state of knowledge, practice guidelines following
the recommendations of the CDC, including use of an
alcohol-based skin preparation, administering appropriate
antimicrobial prophylaxis, and maintaining normo-
thermia and euglycemia, should be the focus of the entire
perioperative team in order to best protect our patients
and decrease the incidence of surgical site infections.
Author Contributions
Study conception and design: Sujka, Oyetunji, St Peter
Acquisition of data: Svetanoff, Dekonenko, Briggs, Sujka,
Osuchukwu, Dorman
Analysis and interpretation of data: Svetanoff, Deko-
nenko, Briggs, Sujka, Osuchukwu, Dorman, Oyetunji
330 Svetanoff et al Surgical Attire and Surgical Site Infection
Drafting of manuscript: Svetanoff, Dekonenko, Briggs,
Sujka, Osuchukwu, Dorman, Oyetunji, St Peter
Critical revision: Svetanoff, Dekonenko, Briggs, Sujka,
Osuchukwu, Dorman, Oyetunji, St Peter
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331.e1 Svetanoff et al Surgical Attire and Surgical Site Infection
APPENDIX
eDocument 1. Search terms - Question #1: Does
complete coverage of the arms of perioperative
team members, both scrubbed and nonscrubbed,
decrease surgical site infection?
-PUBMED:
((("surgical attire"[mh] OR "protective clothing"[mh])
AND "Upper Extremity"[mh]) OR sleeve*[tw] OR ((cov-
er*[tw] OR gown*[tw]) AND (arm[tw] OR arms[tw] OR
forearm[tw] OR elbow[tw] OR wrist[tw] OR "upper
extremity"[tw]))) AND (Infection[mh] OR "Equipment
Contamination"[mh] OR "Bacterial Load"[mh] OR
"Bacterial Infections"[mh] OR Infect*[tw] OR ssi[tw]
OR contaminat*[tw] OR (bacteria*[tw] AND (load*[tw]
OR count[tw] OR counts[tw]))) AND ("Surgical Proced-
ures, Operative"[mh] OR "Operating Rooms"[mh] OR
“Surgeons”[mh] OR "Perioperative Care"[mh] OR "Peri-
operative Nursing"[mh] OR anesthetists[mh] OR surgery
[tw] OR surgical*[tw] OR operation[tw] OR operations
[tw] OR operative*[tw] OR operating[tw] OR perioper-
at*[tw] OR postoperat*[tw] OR preoperat*[tw] OR
peri-operat*[tw] OR post-operat*[tw] OR pre-oper-
at*[tw] OR surgeon[tw] OR "operating room person-
nel"[tw] OR Anesthetist[tw] OR anesthesiologist[tw])
AND English[la] AND 2000/01/01:2019[dp] NOT
"sleeve gastrectomy"[tiab]
-EMBASE:
#1 ’surgical attire’/exp OR sleeve*:ti,ab OR ((cover*:ti,ab
OR gown*:ti,ab) AND (arm:ti,ab OR arms:ti,ab OR
forearm:ti,ab OR elbow:ti,ab OR wrist:ti,ab OR "up-
per extremity":ti,ab))
#2 ’infection’/exp OR ’contamination’/exp OR ’medical
device contamination’/exp OR ’surgical infection’/
exp OR ’device infection’/exp OR ’postoperative
infection’/exp OR ’wound infection’/exp OR ’bacte-
rial load’/exp OR Infect*:ti,ab OR ssi:ti,ab OR con-
taminat*:ti,ab OR (bacteria*:ti,ab AND (load*:ti,ab
OR count:ti,ab OR counts:ti,ab))
#3 ’surgery’/exp OR ’operating room’/exp OR ’surgeon’/
exp OR ’operating room personnel’/exp OR ’periop-
erative nursing’/exp OR surgery:ti,ab OR surgical*:-
ti,ab OR operation:ti,ab OR operations:ti,ab OR
operative*:ti,ab OR operating:ti,ab OR perioperat*:-
ti,ab OR postoperat*:ti,ab OR preoperat*:ti,ab OR
peri-operat*:ti,ab OR post-operat*:ti,ab OR pre-oper-
at*:ti,ab OR surgeon:ti,ab OR "operating room
J Am Coll Surg
personnel":ti,ab OR Anesthetist:ti,ab OR
anesthesiologist:ti,ab
#4 #1 AND #2 AND #3 AND [English]/lim AND
([article]/lim OR [article in press]/lim OR [confer-
ence paper]/lim OR [conference review]/lim OR [re-
view]/lim) AND [01-01-2000]/sd
#5 ’sleeve gastrectomy’/exp OR ’gastric sleeve’/exp OR
’compression sleeve’/exp OR ’pneumo sleeve’/exp
OR ’spinal rod sleeve’/exp OR ’compressible limb
sleeve’/exp
#6 #4 NOT #5
-CINAHL:
S1 (((MH "Protective Clothingþ") OR (MH "Uni-
forms")) AND (MH "Upper Extremityþ")) OR
sleeve* OR ((cover* OR gown*) AND (arm OR
arms OR forearm OR elbow OR wrist OR "upper
extremity"))
S2 (MH "Surgical Wound Infection") OR (MH "Bacte-
rial Infectionsþ") OR (MH "Infectionþ") OR (MH
"Equipment Contamination") OR (MH "Microbial
Contaminationþ") OR Infect* OR ssi OR contami-
nat* OR (bacteria* AND (load* OR count OR
counts))
S3 (MH "Surgery, Operativeþ") OR (MH "Operating
Rooms") OR (MH "Operating Room Personnelþ")
OR (MH "Perioperative Nursing") OR (MH "Peri-
operative Careþ") OR surgery OR surgical* OR
operation OR operations OR operative* OR oper-
ating OR perioperat* OR postoperat* OR preoperat*
OR peri-operat* OR post-operat* OR pre-operat*
OR surgeon OR "operating room personnel" OR
Anesthetist OR anesthesiologist
S4 S1 AND S2 AND S3 AND LA English AND RV Y
AND EM 2000101-
-COCHRANE CENTRAL DATABASE:
#1 (([mh "Surgical Attire"] OR [mh "protective
clothing"]) AND [mh "Upper Extremity"]) OR slee-
ve*:ti,ab OR ((cover*:ti,ab OR gown*:ti,ab) AND
(arm:ti,ab OR arms:ti,ab OR forearm:ti,ab OR
elbow:ti,ab OR wrist:ti,ab OR "upper
extremity":ti,ab))
#2 [mh Infection] OR [mh "Equipment Contamina-
tion"] OR [mh "Bacterial Load"] OR [mh "Bacterial
Infections"] OR Infect*:ti,ab OR ssi:ti,ab OR
Vol. 232, No. 3, March 2021 Svetanoff et al
contaminat*:ti,ab OR (bacteria*:ti,ab AND (load*:-
ti,ab OR count:ti,ab OR counts:ti,ab))
#3 [mh "Surgical Procedures, Operative"] OR [mh
"Operating Rooms"] OR [mh Surgeons] OR [mh
"Perioperative Care"] OR [mh "Perioperative
Nursing"] OR [mh Anesthetists] OR surgery:ti,ab
OR surgical*:ti,ab OR operation:ti,ab OR operation-
s:ti,ab OR operative*:ti,ab OR operating:ti,ab OR
perioperat*:ti,ab OR postoperat*:ti,ab OR preoper-
at*:ti,ab OR peri-operat*:ti,ab OR post-operat*:ti,ab
OR pre-operat*:ti,ab OR surgeon:ti,ab OR "operating
room personnel":ti,ab OR Anesthetist:ti,ab OR
anesthesiologist:ti,ab
#4 #1 AND #2 AND #3
With Publication Year from 2000 to 2019, in Trials
eDocument 2: Search terms - Question #2: Does
disinfection of electronic devices in the periopera-
tive (operating room) setting decrease surgical site
infections in patients?
-PUBMED:
((Fomites[mh] OR Electronics[mh] OR Cell phones
[mh] OR Microcomputers[mh] OR Fomite*[tw] OR
electronic*[tw] OR tablet*[tw] OR ipad*[tw] OR com-
puter*[tw] OR laptop*[tw] OR phone*[tw] OR ipho-
ne*[tw] OR smartphone[tw]) AND (Sterilization[mh]
OR Disinfectants[mh] OR Decontamination[mh] OR
steriliz*[tw] OR disinfect*[tw] OR decontamin*[tw]))
AND ("Surgical Procedures, Operative"[mh] OR "Oper-
ating Rooms"[mh] OR “Surgeons”[mh] OR "Periopera-
tive Care"[mh] OR "Perioperative Nursing"[mh] OR
anesthetists[mh] OR surgery[tw] OR surgical*[tw] OR
operation[tw] OR operations[tw] OR operative*[tw]
OR operating[tw] OR perioperat*[tw] OR postoper-
at*[tw] OR preoperat*[tw] OR peri-operat*[tw] OR
post-operat*[tw] OR pre-operat*[tw] OR surgeon[tw]
OR "operating room personnel"[tw] OR Anesthetist[tw]
OR anesthesiologist[tw]) AND English[la] AND 2000/
01/01:2019/12/31[dp]
-EMBASE:
#1 ’fomite’/exp OR ’microcomputer’/exp OR ’personal
computer’/exp OR ’mobile phone’/exp OR ’elec-
tronics’/exp OR Fomite*:ti,ab OR
electronic*:ti,ab OR tablet*:ti,ab OR ipad*:ti,ab OR
computer*:ti,ab OR laptop*:ti,ab OR phone*:ti,ab
OR iphone*:ti,ab OR smartphone:ti,ab
#2 ’instrument sterilization’/exp OR ’disinfection’/exp
OR steriliz*:ti,ab OR disinfect*:ti,ab OR
decontamin*:ti,ab
#3 #1 AND #2
Surgical Attire and Surgical Site Infection 331.e2
#4 ’surgery’/exp OR ’operating room’/exp OR ’surgeon’/
exp OR ’operating room personnel’/exp OR ’periop-
erative nursing’/exp OR surgery:ti,ab OR surgical*:-
ti,ab OR operation:ti,ab OR operations:ti,ab OR
operative*:ti,ab OR operating:ti,ab OR perioperat*:-
ti,ab OR postoperat*:ti,ab OR preoperat*:ti,ab OR
peri-operat*:ti,ab OR post-operat*:ti,ab OR pre-oper-
at*:ti,ab OR surgeon:ti,ab OR "operating room per-
sonnel":ti,ab OR Anesthetist:ti,ab OR
anesthesiologist:ti,ab
#5 #3 AND #4 AND [English]/lim AND ([article]/lim
OR [article in press]/lim OR [conference paper]/lim
OR [conference review]/lim OR [review]/lim) AND
[01-01-2000]/sd
-CINAHL:
S1 (MH "Microcomputersþ") OR (MH "Electro-
nicsþ") OR Fomite* OR electronic* OR tablet*
OR ipad* OR computer* OR laptop* OR phone*
OR iphone* OR smartphone
S2 (MH "Sterilization and Disinfection") OR steriliz*
OR disinfect* OR decontamin*
S3 S1 AND S2
S4 (MH "Surgery, Operativeþ") OR (MH "Operating
Rooms") OR (MH "Operating Room Personnelþ")
OR (MH "Perioperative Nursing") OR (MH "Peri-
operative Careþ") OR surgery OR surgical* OR
operation OR operations OR operative* OR oper-
ating OR perioperat* OR postoperat* OR preoperat*
OR peri-operat* OR post-operat* OR pre-operat*
OR surgeon OR "operating room personnel" OR
Anesthetist OR anesthesiologist
S5 S3 AND S4 AND EM 20000101- AND LA English
AND RV Y
-COCHRANE CENTRAL DATABASE:
#1 [mh Fomites] OR [mh Electronics] OR [mh "Cell
phones"] OR [mh Microcomputers] OR Fomite*:-
ti,ab OR electronic*:ti,ab OR tablet*:ti,ab OR ipad*:-
ti,ab OR computer*:ti,ab OR laptop*:ti,ab OR
phone*:ti,ab OR iphone*:ti,ab OR smartphone:ti,ab
#2 [mh Sterilization] OR [mh Disinfectants] OR [mh
Decontamination] OR steriliz*:ti,ab OR disinfect*:-
ti,ab OR decontamin*:ti,ab
#3 #1 AND #2
#4 [mh "Surgical Procedures, Operative"] OR [mh
"Operating Rooms"] OR [mh Surgeons] OR [mh
"Perioperative Care"] OR [mh "Perioperative
Nursing"] OR [mh Anesthetists] OR surgery:ti,ab
OR surgical*:ti,ab OR operation:ti,ab OR
331.e3 Svetanoff et al Surgical Attire and Surgical Site Infection
operations:ti,ab OR operative*:ti,ab OR operating:-
ti,ab OR perioperat*:ti,ab OR postoperat*:ti,ab OR
preoperat*:ti,ab OR peri-operat*:ti,ab OR post-oper-
at*:ti,ab OR pre-operat*:ti,ab OR surgeon:ti,ab OR
"operating room personnel":ti,ab OR Anesthetist:ti,ab
OR anesthesiologist:ti,ab
#5 #3 AND #4
Limit: with Publication Year from 2000 to 2019, in
Trials
eDocument 3. Search terms - Question #3: Does
full gown use by perioperative personnel decrease
surgical site infection?
-PUBMED:
(("surgical attire"[mh] OR "protective clothing"[mh])
OR (Gown*[tw] AND (full[tw] OR complete[tw])))
AND (Infection[mh] OR "Equipment Contamina-
tion"[mh] OR "Bacterial Load"[mh] OR "Bacterial Infec-
tions"[mh] OR Infect*[tw] OR ssi[tw] OR
contaminat*[tw] OR (bacteria*[tw] AND (load*[tw]
OR count[tw] OR counts[tw]))) AND ("Surgical Proced-
ures, Operative"[mh] OR "Operating Rooms"[mh] OR
“Surgeons”[mh] OR "Perioperative Care"[mh] OR "Peri-
operative Nursing"[mh] OR anesthetists[mh] OR surgery
[tw] OR surgical*[tw] OR operation[tw] OR operations
[tw] OR operative*[tw] OR operating[tw] OR perioper-
at*[tw] OR postoperat*[tw] OR preoperat*[tw] OR
peri-operat*[tw] OR post-operat*[tw] OR pre-oper-
at*[tw] OR surgeon[tw] OR "operating room person-
nel"[tw] OR Anesthetist[tw] OR anesthesiologist[tw])
AND English[la] AND 2000/01/01:2019[dp]
-EMBASE:
#1 ’surgical gown’/exp OR (Gown*:ti,ab AND (full:ti,ab
OR complete:ti,ab))
#2 ’infection’/exp OR ’contamination’/exp OR ’medical
device contamination’/exp OR ’surgical infection’/
exp OR ’device infection’/exp OR ’postoperative
infection’/exp OR ’wound infection’/exp OR ’bacte-
rial load’/exp OR Infect*:ti,ab OR ssi:ti,ab OR con-
taminat*:ti,ab OR (bacteria*:ti,ab AND (load*:ti,ab
OR count:ti,ab OR counts:ti,ab))
#3 ’surgery’/exp OR ’operating room’/exp OR ’surgeon’/
exp OR ’operating room personnel’/exp OR ’periop-
erative nursing’/exp OR surgery:ti,ab OR surgical*:-
ti,ab OR operation:ti,ab OR operations:ti,ab OR
operative*:ti,ab OR operating:ti,ab OR perioperat*:-
ti,ab OR postoperat*:ti,ab OR preoperat*:ti,ab OR
peri-operat*:ti,ab OR post-operat*:ti,ab OR pre-oper-
at*:ti,ab OR surgeon:ti,ab OR "operating room
J Am Coll Surg
personnel":ti,ab OR Anesthetist:ti,ab OR
anesthesiologist:ti,ab
#4 #1 AND #2 AND #3 AND [English]/lim AND
([article]/lim OR [article in press]/lim OR [confer-
ence paper]/lim OR [conference review]/lim OR [re-
view]/lim) AND [01-01-2000]/sd
-CINAHL:
S1 (MH "Protective Clothingþ") OR (MH "Uniforms")
OR (Gown* AND (full OR complete))
S2 (MH "Surgical Wound Infection") OR (MH "Bacte-
rial Infectionsþ") OR (MH "Infectionþ") OR (MH
"Equipment Contamination") OR (MH "Microbial
Contaminationþ") OR Infect* OR ssi OR contami-
nat* OR (bacteria* AND (load* OR count OR
counts))
S3 (MH "Surgery, Operativeþ") OR (MH "Operating
Rooms") OR (MH "Operating Room Personnelþ")
OR (MH "Perioperative Nursing") OR (MH "Peri-
operative Careþ") OR surgery OR surgical* OR
operation OR operations OR operative* OR oper-
ating OR perioperat* OR postoperat* OR preoperat*
OR peri-operat* OR post-operat* OR pre-operat*
OR surgeon OR "operating room personnel" OR
Anesthetist OR anesthesiologist
S4 S1 AND S2 AND S3 AND LA English AND RV Y
AND EM 20000101-
-COCHRANE CENTRAL DATABASE:
#1 [mh "Surgical Attire"] OR (Gown*:ti,ab AND (full:-
ti,ab OR complete:ti,ab))
#2 [mh Infection] OR [mh "Equipment Contamina-
tion"] OR [mh "Bacterial Load"] OR [mh "Bacterial
Infections"] OR Infect*:ti,ab OR ssi:ti,ab OR con-
taminat*:ti,ab OR (bacteria*:ti,ab AND (load*:ti,ab
OR count:ti,ab OR counts:ti,ab))
#3 [mh "Surgical Procedures, Operative"] OR [mh
"Operating Rooms"] OR [mh Surgeons] OR [mh
"Perioperative Care"] OR [mh "Perioperative
Nursing"] OR [mh Anesthetists] OR surgery:ti,ab
OR surgical*:ti,ab OR operation:ti,ab OR operation-
s:ti,ab OR operative*:ti,ab OR operating:ti,ab OR
perioperat*:ti,ab OR postoperat*:ti,ab OR preoper-
at*:ti,ab OR peri-operat*:ti,ab OR post-operat*:ti,ab
OR pre-operat*:ti,ab OR surgeon:ti,ab OR "operating
room personnel":ti,ab OR Anesthetist:ti,ab OR
anesthesiologist:ti,ab
#4 #1 AND #2 AND #3
With Publication Year from 2000 to 2019, in Trials
Vol. 232, No. 3, March 2021 Svetanoff et al
eDocument 4. Search terms - Question #4: Does
complete coverage of the head, including hair,
ears, facial hair (sideburns), and nape of the neck
by a clean surgical head cover by perioperative
team members (in semi-restricted and restricted
areas) decrease surgical site infection?
-PUBMED:
((("surgical attire"[mh] OR Masks[mh] OR "protective
clothing"[mh]) AND (Head[mh] OR Hair[mh] OR
Neck[mh])) OR ((cover*[tw] OR cap[tw] OR mask[tw]
OR hat[tw] OR cloth*[tw]) AND (head[tw] OR hair
[tw] OR beard[tw] OR sideburn*[tw] OR ear[tw] OR
ears[tw] OR neck[tw] OR nape[tw] OR scalp[tw])))
AND (Infection[mh] OR "Equipment Contamina-
tion"[mh] OR "Bacterial Load"[mh] OR "Bacterial Infec-
tions"[mh] OR Infect*[tw] OR ssi[tw] OR
contaminat*[tw] OR (bacteria*[tw] AND (load*[tw]
OR count[tw] OR counts[tw]))) AND ("Surgical Proced-
ures, Operative"[mh] OR "Operating Rooms"[mh] OR
“Surgeons”[mh] OR "Perioperative Care"[mh] OR "Peri-
operative Nursing"[mh] OR anesthetists[mh] OR surgery
[tw] OR surgical*[tw] OR operation[tw] OR operations
[tw] OR operative*[tw] OR operating[tw] OR perioper-
at*[tw] OR postoperat*[tw] OR preoperat*[tw] OR
peri-operat*[tw] OR post-operat*[tw] OR pre-oper-
at*[tw] OR surgeon[tw] OR "operating room person-
nel"[tw] OR Anesthetist[tw] OR anesthesiologist[tw])
AND English[la] AND 2000/01/01:2019[dp]
-EMBASE:
#1 ((’surgical attire’/exp OR ’surgical mask’/exp OR
’protective clothing’/exp) AND (’head’/exp OR
’hair’/exp OR ’scalp’/exp OR ’neck’/de OR ’nape’/
exp)) OR ((cover*:ti,ab OR cap:ti,ab OR mask:ti,ab
OR hat:ti,ab OR cloth*:ti,ab) AND (head:ti,ab OR
hair:ti,ab OR beard:ti,ab OR sideburn*:ti,ab OR ear:-
ti,ab OR ears:ti,ab OR neck:ti,ab OR nape:ti,ab OR
scalp:ti,ab))
#2 ’infection’/exp OR ’contamination’/exp OR ’medical
device contamination’/exp OR ’surgical infection’/
exp OR ’device infection’/exp OR ’postoperative
infection’/exp OR ’wound infection’/exp OR ’bacte-
rial load’/exp OR Infect*:ti,ab OR ssi:ti,ab OR con-
taminat*:ti,ab OR (bacteria*:ti,ab AND (load*:ti,ab
OR count:ti,ab OR counts:ti,ab))
#3 ’surgery’/exp OR ’operating room’/exp OR ’surgeon’/
exp OR ’operating room personnel’/exp OR ’periop-
erative nursing’/exp OR surgery:ti,ab OR surgical*:-
ti,ab OR operation:ti,ab OR operations:ti,ab OR
operative*:ti,ab OR operating:ti,ab OR perioperat*:-
ti,ab OR postoperat*:ti,ab OR preoperat*:ti,ab OR
Surgical Attire and Surgical Site Infection 331.e4
peri-operat*:ti,ab OR post-operat*:ti,ab OR pre-oper-
at*:ti,ab OR surgeon:ti,ab OR "operating room per-
sonnel":ti,ab OR Anesthetist:ti,ab OR
anesthesiologist:ti,ab
#4 #1 AND #2 AND #3 AND [English]/lim AND
([article]/lim OR [article in press]/lim OR [confer-
ence paper]/lim OR [conference review]/lim OR [re-
view]/lim) AND [01-01-2000]/sd
-CINAHL:
S1 ((MH "Protective Clothing") OR (MH "Uniforms")
OR (MH "Masks")) AND ((MH "Headþ") OR
(MH "Neck") OR (MH "Scalp") OR (MH
"Hairþ")) OR ((cover* OR cap OR mask OR hat
OR cloth*) AND (head OR hair OR beard OR side-
burn* OR ear OR ears OR neck OR nape OR scalp))
S2 (MH "Surgical Wound Infection") OR (MH "Bacte-
rial Infectionsþ") OR (MH "Infectionþ") OR (MH
"Equipment Contamination") OR (MH "Microbial
Contaminationþ") OR Infect* OR ssi OR contami-
nat* OR (bacteria* AND (load* OR count OR
counts))
S3 (MH "Surgery, Operativeþ") OR (MH "Operating
Rooms") OR (MH "Operating Room Personnelþ")
OR (MH "Perioperative Nursing") OR (MH "Peri-
operative Careþ") OR surgery OR surgical* OR
operation OR operations OR operative* OR oper-
ating OR perioperat* OR postoperat* OR preoperat*
OR peri-operat* OR post-operat* OR pre-operat*
OR surgeon OR "operating room personnel" OR
Anesthetist OR anesthesiologist
S4 S1 AND S2 AND S3 AND LA English AND RV Y
AND EM 20000101-
-COCHRANE CENTRAL DATABASE:
#1 (([mh "surgical attire"] OR [mh Masks] OR [mh
"protective clothing"]) AND ([mh Head] OR [mh
Hair] OR [mh Neck])) OR ((cover*:ti,ab OR cap:-
ti,ab OR mask:ti,ab OR hat:ti,ab OR cloth*:ti,ab)
AND (head:ti,ab OR hair:ti,ab OR beard:ti,ab OR
sideburn*:ti,ab OR ear:ti,ab OR ears:ti,ab OR neck:-
ti,ab OR nape:ti,ab OR scalp:ti,ab))
#2 [mh Infection] OR [mh "Equipment Contamina-
tion"] OR [mh "Bacterial Load"] OR [mh "Bacterial
Infections"] OR Infect*:ti,ab OR ssi:ti,ab OR con-
taminat*:ti,ab OR (bacteria*:ti,ab AND (load*:ti,ab
OR count:ti,ab OR counts:ti,ab))
#3 [mh "Surgical Procedures, Operative"] OR [mh
"Operating Rooms"] OR [mh Surgeons] OR [mh
331.e5 Svetanoff et al Surgical Attire and Surgical Site Infection
"Perioperative Care"] OR [mh "Perioperative
Nursing"] OR [mh Anesthetists] OR surgery:ti,ab
OR surgical*:ti,ab OR operation:ti,ab OR operation-
s:ti,ab OR operative*:ti,ab OR operating:ti,ab OR
perioperat*:ti,ab OR postoperat*:ti,ab OR preoper-
at*:ti,ab OR peri-operat*:ti,ab OR post-operat*:ti,ab
OR pre-operat*:ti,ab OR surgeon:ti,ab OR "operating
room personnel":ti,ab OR Anesthetist:ti,ab OR
anesthesiologist:ti,ab
#4 #1 AND #2 AND #3
With Publication Year from 2000 to 2019, in Trials
eDocument 5. Search terms - Question #5: Does it
decrease surgical site infection if perioperative
personnel: a) Change into street clothes when
leaving the building, and b) leave reusable scrub
attire and reusable head covers at healthcare
facility for laundering onsite?
-PUBMED:
((“Laundry Service, Hospital”[mh] OR (“Launder-
ing”[mh] AND Hospitals[mh])) OR ((laundr*[tw] OR
launder*[tw] OR “washing machine” [tw] OR “washing
machines”[tw]) AND (hospital[tw] OR hospitals[tw]
OR hospitaliz*[tw] OR surgical[tw] OR surgery[tw] OR
institution*[tw] OR workplace[tw])) OR ((clothes[tw]
OR clothing[tw] OR attire[tw]) AND (chang*[tw] OR
replace[tw] OR exchang*[tw]) AND (leave[tw] OR
street[tw] OR outside[tw] OR home[tw] OR "after
work"[tw] OR "end of shift"[tw] OR "off-shift"[tw]
OR "off work"[tw] OR "clock out"[tw]))) AND (Infec-
tion[mh] OR "Equipment Contamination"[mh] OR
"Bacterial Load"[mh] OR "Bacterial Infections"[mh]
OR Infect*[tw] OR ssi[tw] OR contaminat*[tw] OR
(bacteria*[tw] AND (load*[tw] OR count[tw] OR
counts[tw]))) AND ("Surgical Procedures, Operati-
ve"[mh] OR "Operating Rooms"[mh] OR “Sur-
geons”[mh] OR "Perioperative Care"[mh] OR
"Perioperative Nursing"[mh] OR anesthetists[mh] OR
surgery[tw] OR surgical*[tw] OR operation[tw] OR op-
erations[tw] OR operative*[tw] OR operating[tw] OR
perioperat*[tw] OR postoperat*[tw] OR preoperat*[tw]
OR peri-operat*[tw] OR post-operat*[tw] OR pre-oper-
at*[tw] OR surgeon[tw] OR "operating room person-
nel"[tw] OR Anesthetist[tw] OR anesthesiologist[tw])
AND English[la] AND 2000/01/01:2019[dp]
-EMBASE:
#1 ’laundry’/exp OR ((laundr*:ti,ab OR launder*:ti,ab
OR “washing machine”:ti,ab OR “washing machi-
nes”:ti,ab) AND (hospital*:ti,ab OR surgical:ti,ab
J Am Coll Surg
OR surgery:ti,ab OR institution*:ti,ab OR workpla-
ce:ti,ab)) OR ((clothes:ti,ab OR clothing:ti,ab OR
attire:ti,ab) AND (chang*:ti,ab OR replace:ti,ab OR
exchang*:ti,ab) AND (leave:ti,ab OR street:ti,ab OR
outside:ti,ab OR home:ti,ab OR "after work":ti,ab
OR "end of shift":ti,ab OR "off-shift":ti,ab OR "off
work":ti,ab OR "clock out":ti,ab))
#2 ’infection’/exp OR ’contamination’/exp OR ’medical
device contamination’/exp OR ’surgical infection’/
exp OR ’device infection’/exp OR ’postoperative
infection’/exp OR ’wound infection’/exp OR ’bacte-
rial load’/exp OR Infect*:ti,ab OR ssi:ti,ab OR con-
taminat*:ti,ab OR (bacteria*:ti,ab AND (load*:ti,ab
OR count:ti,ab OR counts:ti,ab))
#3 ’surgery’/exp OR ’operating room’/exp OR ’surgeon’/
exp OR ’operating room personnel’/exp OR ’periop-
erative nursing’/exp OR surgery:ti,ab OR surgical*:-
ti,ab OR operation:ti,ab OR operations:ti,ab OR
operative*:ti,ab OR operating:ti,ab OR perioperat*:-
ti,ab OR postoperat*:ti,ab OR preoperat*:ti,ab OR
peri-operat*:ti,ab OR post-operat*:ti,ab OR pre-oper-
at*:ti,ab OR surgeon:ti,ab OR "operating room per-
sonnel":ti,ab OR Anesthetist:ti,ab OR
anesthesiologist:ti,ab
#4 #1 AND #2 AND #3 AND [English]/lim AND
([article]/lim OR [article in press]/lim OR [confer-
ence paper]/lim OR [conference review]/lim OR [re-
view]/lim) AND [01-01-2000]/sd
-CINAHL:
S1 (MH "Laundry Department") OR ((laundr* OR
launder* OR “washing machine” OR “washing ma-
chines”) AND (hospital* OR surgical OR surgery
OR institution* OR workplace)) OR ((clothes OR
clothing OR attire) AND (chang* OR replace OR
exchang*) AND (leave OR street OR outside OR
home OR "after work" OR "end of shift" OR "off-
shift" OR "off work" OR "clock out"))
S2 (MH "Surgical Wound Infection") OR (MH "Bacte-
rial Infectionsþ") OR (MH "Infectionþ") OR (MH
"Equipment Contamination") OR (MH "Microbial
Contaminationþ") OR Infect* OR ssi OR contami-
nat* OR (bacteria* AND (load* OR count OR
counts))
S3 (MH "Surgery, Operativeþ") OR (MH "Operating
Rooms") OR (MH "Operating Room Personnelþ")
OR (MH "Perioperative Nursing") OR (MH "Peri-
operative Careþ") OR surgery OR surgical* OR
operation OR operations OR operative* OR
Vol. 232, No. 3, March 2021 Svetanoff et al
operating OR perioperat* OR postoperat* OR preop-
erat* OR peri-operat* OR post-operat* OR pre-
operat* OR surgeon OR "operating room personnel"
OR Anesthetist OR anesthesiologist
S4 S1 AND S2 AND S3 AND LA English AND RV Y
AND EM 20000101-
-COCHRANE CENTRAL DATABASE:
#1 ([mh “Laundry Service, Hospital”] OR ([mh Laun-
dering] AND [mh Hospitals])) OR ((laundr*:ti,ab
OR launder*:ti,ab OR “washing machine”:ti,ab OR
“washing machines”:ti,ab) AND (hospital*:ti,ab OR
surgical:ti,ab OR surgery:ti,ab OR institution*:ti,ab
OR workplace:ti,ab)) OR ((clothes:ti,ab OR clo-
thing:ti,ab OR attire:ti,ab) AND (chang*:ti,ab OR
replace:ti,ab OR exchang*:ti,ab) AND (leave:ti,ab
OR street:ti,ab OR outside:ti,ab OR home:ti,ab OR
"after work":ti,ab OR "end of shift":ti,ab OR "off-
shift":ti,ab OR "off work":ti,ab OR "clock out":ti,ab))
#2 [mh Infection] OR [mh "Equipment Contamina-
tion"] OR [mh "Bacterial Load"] OR [mh "Bacterial
Infections"] OR Infect*:ti,ab OR ssi:ti,ab OR con-
taminat*:ti,ab OR (bacteria*:ti,ab AND (load*:ti,ab
OR count:ti,ab OR counts:ti,ab))
#3 [mh "Surgical Procedures, Operative"] OR [mh
"Operating Rooms"] OR [mh Surgeons] OR [mh
"Perioperative Care"] OR [mh "Perioperative
Nursing"] OR [mh Anesthetists] OR surgery:ti,ab
OR surgical*:ti,ab OR operation:ti,ab OR operation-
s:ti,ab OR operative*:ti,ab OR operating:ti,ab OR
perioperat*:ti,ab OR postoperat*:ti,ab OR preoper-
at*:ti,ab OR peri-operat*:ti,ab OR post-operat*:ti,ab
OR pre-operat*:ti,ab OR surgeon:ti,ab OR "operating
room personnel":ti,ab OR Anesthetist:ti,ab OR
anesthesiologist:ti,ab
#4 #1 AND #2 AND #3
With Publication Year from 2000 to 2019, in Trials
eDocument 6. Search terms - Question #6: Does
shedding of skin and hair from perioperative
personnel increase surgical site infection?
-PUBMED:
("Bacterial Shedding"[Mesh] OR dandruff[mh] OR
Dander[mh] OR Dandruff[tw] OR dander[tw]
OR ((“Skin”[Mesh] OR skin[tw] OR “Hair”[Mesh] OR
hair[tw]) AND (shed[tw] OR shedding[tw] OR
shedded[tw] OR slough[tw] OR exfoliat*[tw]))) AND
(Infection[mh] OR "Equipment Contamination"[mh]
OR "Bacterial Load"[mh] OR "Bacterial Infections"[mh]
Surgical Attire and Surgical Site Infection 331.e6
OR Infect*[tw] OR ssi[tw] OR contaminat*[tw] OR
(bacteria*[tw] AND (load*[tw] OR count[tw] OR
counts[tw]))) AND ("Surgical Procedures, Operati-
ve"[mh] OR "Operating Rooms"[mh] OR “Sur-
geons”[mh] OR "Perioperative Care"[mh] OR
"Perioperative Nursing"[mh] OR anesthetists[mh] OR
surgery[tw] OR surgical*[tw] OR operation[tw] OR op-
erations[tw] OR operative*[tw] OR operating[tw] OR
perioperat*[tw] OR postoperat*[tw] OR preoperat*[tw]
OR peri-operat*[tw] OR post-operat*[tw] OR pre-oper-
at*[tw] OR surgeon[tw] OR "operating room person-
nel"[tw] OR Anesthetist[tw] OR anesthesiologist[tw])
AND English[la] AND 2000/01/01:2019[dp]
-EMBASE:
#1 ’bacterial shedding’/exp OR ’dandruff’/exp OR
’dander’/exp OR Dandruff:ti,ab OR dander:ti,ab
OR ((’skin’/exp OR Skin:ti,ab OR ’hair’/exp OR
Hair:ti,ab) AND (shed:ti,ab OR shedding:ti,ab
OR shedded:ti,ab OR slough:ti,ab OR
exfoliat*:ti,ab))
#2 ’infection’/exp OR ’contamination’/exp OR ’medical
device contamination’/exp OR ’surgical infection’/
exp OR ’device infection’/exp OR ’postoperative
infection’/exp OR ’wound infection’/exp OR ’bacte-
rial load’/exp OR Infect*:ti,ab OR ssi:ti,ab OR con-
taminat*:ti,ab OR (bacteria*:ti,ab AND (load*:ti,ab
OR count:ti,ab OR counts:ti,ab))
#3 ’surgery’/exp OR ’operating room’/exp OR ’surgeon’/
exp OR ’operating room personnel’/exp OR ’periop-
erative nursing’/exp OR surgery:ti,ab OR surgical*:-
ti,ab OR operation:ti,ab OR operations:ti,ab OR
operative*:ti,ab OR operating:ti,ab OR perioperat*:-
ti,ab OR postoperat*:ti,ab OR preoperat*:ti,ab OR
peri-operat*:ti,ab OR post-operat*:ti,ab OR pre-oper-
at*:ti,ab OR surgeon:ti,ab OR "operating room per-
sonnel":ti,ab OR Anesthetist:ti,ab OR
anesthesiologist:ti,ab
#4 #1 AND #2 AND #3 AND [English]/lim AND
([article]/lim OR [article in press]/lim OR [confer-
ence paper]/lim OR [conference review]/lim OR [re-
view]/lim) AND [01-01-2000]/sd
-CINAHL:
S1 (Dandruff OR dander OR (((MH "Skinþ") OR Skin
OR Hair OR bacterial) AND (shed OR shedding OR
shedded OR slough OR exfoliat*))
S2 (MH "Surgical Wound Infection") OR (MH "Bacte-
rial Infectionsþ") OR (MH "Infectionþ") OR (MH
"Equipment Contamination") OR (MH "Microbial
331.e7 Svetanoff et al Surgical Attire and Surgical Site Infection
Contaminationþ") OR Infect* OR ssi OR contami-
nat* OR (bacteria* AND (load* OR count OR
counts))
S3 (MH "Surgery, Operativeþ") OR (MH "Operating
Rooms") OR (MH "Operating Room Personnelþ")
OR (MH "Perioperative Nursing") OR (MH "Peri-
operative Careþ") OR surgery OR surgical* OR
operation OR operations OR operative* OR oper-
ating OR perioperat* OR postoperat* OR preoperat*
OR peri-operat* OR post-operat* OR pre-operat*
OR surgeon OR "operating room personnel" OR
Anesthetist OR anesthesiologist
S4 S1 AND S2 AND S3 AND LA English AND RV Y
AND EM 20000101-
-COCHRANE CENTRAL DATABASE:
#1 [mh "Bacterial Shedding"] OR [mh Dandruff] OR
[mh Dander] OR Dandruff:ti,ab OR dander:ti,ab
OR (([mh “Skin”] OR skin:ti,ab OR [mh “Hair”]
OR hair:ti,ab) AND (shed:ti,ab OR shedding:ti,ab
J Am Coll Surg
OR shedded:ti,ab OR slough:ti,ab OR
exfoliat*:ti,ab))
#2 [mh Infection] OR [mh "Equipment Contamina-
tion"] OR [mh "Bacterial Load"] OR [mh "Bacterial
Infections"] OR Infect*:ti,ab OR ssi:ti,ab OR con-
taminat*:ti,ab OR (bacteria*:ti,ab AND (load*:ti,ab
OR count:ti,ab OR counts:ti,ab))
#3 [mh "Surgical Procedures, Operative"] OR [mh "Oper-
ating Rooms"] OR [mh Surgeons] OR [mh "Periopera-
tive Care"] OR [mh "Perioperative Nursing"] OR [mh
Anesthetists] OR surgery:ti,ab OR surgical*:ti,ab OR
operation:ti,ab OR operations:ti,ab OR operative*:ti,ab
OR operating:ti,ab OR perioperat*:ti,ab OR postoper-
at*:ti,ab OR preoperat*:ti,ab OR peri-operat*:ti,ab OR
post-operat*:ti,ab OR pre-operat*:ti,ab OR surgeon:-
ti,ab OR "operating room personnel":ti,ab OR Anesthe-
tist:ti,ab OR anesthesiologist:ti,ab
#4 #1 AND #2 AND #3
With Publication Year from 2010 to 2019, in Trials