Reduction Of Surgical Site Infections Research Articles

Outcomes of extended-spectrum beta-lactamases producing Enterobacteriaceae colonization among patients abdominal surgery patients.

Preoperative enteric screening for extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae was conducted in 360 patients prospectively observed for surgical site infection (SSI). ESBL colonization (adjusted odds ratio [aOR], 2.4) and dirty wound classification (aOR, 3.6) were associated with SSI; no association between carbapenem prophylaxis and reduction in SSI was detected.

Use of incisional vacuum-assisted closure in the prevention of postoperative infection in high-risk patients who underwent spine surgery: a proof-of-concept study.

This proof-of-concept study was conducted to determine whether negative-pressure wound therapy, through the use of incisional vacuum-assisted closure (VAC), is associated with a reduction in surgical site infections (SSIs) when compared to standard wound dressings in patients undergoing open posterior spinal fusion who have a high risk of infection. A total of 64 patients were examined; 21 patients received incisional VAC application (VAC group) versus 43 diagnosis-matched patients who received standard wound dressings (control group). Patients in the VAC group were prospectively enrolled in a consecutive series between March 2013 and March 2014 if they met the following diagnostic criteria for high risk of infection: posterior open surgery across the cervicothoracic junction; thoracic kyphosis due to metastatic disease; high-energy trauma; or multilevel revision reconstructive surgery. Patients in the VAC group also met one or more comorbidity criteria, including body mass index ≥ 35 or < 18.5, diabetes, previous radiation at surgical site, chemotherapy, steroid use, bedridden state, large traumatic soft-tissue disruption, or immunocompromised state. Consecutive patients in the control group were retrospectively selected from the previous year by the same high-risk infection diagnostic criteria as the VAC group. All surgeries were conducted by the same surgeon at a single site. The primary outcome was SSI. All patients had 1 year of follow-up after their surgery. Baseline demographics, intraoperative parameters, and postoperative wound infection rates were compared between groups. Patient demographics including underlying comorbidities were similar, with the exception that VAC-treated patients were malnourished (p = 0.020). VAC-treated patients underwent longer surgeries (p < 0.001) and required more postoperative ICU admissions (p = 0.039). The median length of hospital stay was not different between groups. In total, 9 control patients (21%) developed an SSI, versus 2 VAC-treated patients (10%). Patients in this cohort were selected to have an increased risk of infection; accordingly, the rate of SSI was high. However, negative-pressure wound therapy through VAC application to the postoperative incision resulted in a 50% reduction in SSI. No adverse effects were noted secondary to VAC application. The preliminary data confirm the authors' proof of concept and strongly support the need for a prospective randomized trial.

Local Application of Vancomycin in Spine Surgery Does Not Result in Increased Vancomycin-Resistant Bacteria—10-Year Data

Study DesignCase-control study. ObjectivesTo analyze the microbial flora in surgical spine infections and their antibiotic resistance patterns across time and determine the correlation between vancomycin application in the wound and vancomycin-resistant microbes. Summary of Background DataPrior studies show a reduction in surgical site infections with intrawound vancomycin placement. No data are available on the potential negative effects of this intervention, in particular, whether there would be a resultant increase in vancomycin-resistant organisms or bacterial resistance profiles. MethodsAll culture-positive surgical site infections at a single institution were analyzed from 2007 to 2017. Each bacterium was assessed independently for resistance patterns. The two-tailed Fisher exact test was used to determine the correlation between vancomycin application and the presence of vancomycin-resistant bacteria, polymicrobial infections, or gram-negative bacterial infections. ResultsOne hundred and eight bacteria were isolated from 113 surgical site infections from 2007 to 2017. The most common organisms were staphylococcus with varying resistance patterns and Escherichia coli. Vancomycin-resistant Enterococcus faecium was isolated in three infections. Out of the 4,878 surgical cases from 2011 to 2017, vancomycin was placed in 48.3%, and no vancomycin in 51.7%. There were 33 infections (1.4%) in the vancomycin group and 20 infections (0.8%) in the no-vancomycin group (χ2 = 0.0521). There was no correlation between vancomycin application in the wound and vancomycin-resistant microbes (χ2 = 0.2334) and polymicrobial infections (χ2 = 0.1328). There was an increased rate of gram-negative organisms in infections after vancomycin application in the wound versus no vancomycin (χ2 = 0.0254). ConclusionsTopical vancomycin within the surgical site is not correlated with vancomycin-resistant bacteria. However, there was an increased incidence of gram-negative organisms in infections after vancomycin application in the wound versus no vancomycin. Continued surveillance with prospectively collected randomized data is necessary to better understand bacterial evolution against current antimicrobial techniques. Level of EvidenceLevel III.

Pre-operative skin antisepsis with chlorhexidine gluconate baths and wipes does not prevent postoperative surgical site infection in outpatient pediatric urologic inguinal and scrotal surgery

To reduce surgical site infections (SSI), many institutions utilize pre-operative antisepsis with chlorhexidine gluconate (CHG) baths and/or wipes. CHG reduces bacterial colonization of the skin, but it is unclear whether this reduces SSI, and current guidelines from the American College of Surgeons, the Centers for Disease Control, and the World Health Organization do not support this practice. There are several factors that increase the risk of SSI in adults, but there is limited understanding of these factors in pediatric patients. The primary objectives were to describe the proportion of pediatric patients undergoing hernia/hydrocele repair and/or orchiopexy who develop a postoperative (postop) SSIand to determine whether pre-operative CHG baths/wipes were associated with SSI. The secondary objectives were to identify other factors associated with SSIand to estimate the cost of CHG baths/wipes in this population. Pre-operative antisepsis with CHG baths/wipes was implemented at the authors institution in 2006. The authors performed a retrospective cohort study of patients aged 0-18 yearsundergoing hernia/hydrocele repair and/or orchiopexy by a pediatric urologist at their institution before (2004) and after (2008) the introduction of CHG. The authors compared the proportion of patients with SSI in the no CHG and CHG groups and evaluated for factors associated with SSI. Statistical analysis included Wilcoxon rank-sum test, Chi-squared test, and Fisher's exact test. The cost of CHG baths and wipes was estimated using institutional fees in 2018 US dollars. A total of 543 patients met inclusion criteria,203 in the no CHG group and 340 in the CHG group. The overall rate of SSI was 0.92%. There was no association between use of CHG and SSI. No patient or peri-operative factors were associated with development of SSI. There were no CHG-associated adverse events. The cost of materials was estimated at $3.29/patient ($1118.60 for 340 cases in 2008) in 2018 US dollars. SSI is not common in pediatric patients undergoing hernia/hydrocele repair or orchiopexy. In the present study, pre-operative antisepsis with CHG baths/wipes is not associated with a reduction in SSI and carries additional cost. To the authors knowledge, this is the first study to evaluate the use of pre-operative antisepsis with CHG baths/wipes in an exclusively pediatric population. In the study, CHG baths/wipes add cost with no clear benefit for reducing SSI in pediatric patients undergoing hernia/hydrocele repair and/or orchiopexy.

Surgical Site Infection Reduction: Through Povidone-Iodine Nasal Decolonization Prior to Surgery

Surgical Site Infection Reduction: Through Povidone-Iodine Nasal Decolonization Prior to Surgery

Role of hyperoxygenation on surgical site wound infection: a randomised case control study

Background: The aim of this study was to assess the influence of hyperoxygenation on surgical site wound infections.Methods: Using prospective randomized study, conducted from January 2018 to December 2018 at Mamata Medical College and General hospital, Khammam. This study includes 100 patients who were going for elective surgery at various divisions of Department of surgery. Patients were assigned randomly to an oxygen/air mixture with a faction of inspiration (FiO2) of 30% (n=50) and 60% (n=50). Administration was started after induction of anaesthesia and maintained for 3hours after surgery.Results: Surgical site infection was recorded in 5 patients (2 of 50, 10%) in the hyperoxygenation group and 11 patients (11 of 50, 22%) in the control group (p&lt;0.05). Time of hospitalization was 5±3 days in the hyperoxygenation group and 9±4 days in the control group (p&lt;0.05).Conclusions: Hyperoxygenation was associated with a reduction in surgical site infection. It also decreases the duration of hospital stay and decreases economic burden.

Patient-Directed Active Surgical Incisions Surveillance May Lead to Further Surgical Site Infection Reduction.

Background: Surgical site infections have been a concern for many years, and decades-old articles demonstrate the benefit of surveillance and reporting of these infections with resulting decrease in incidence. Comprehensive surveillance is difficult and often incomplete and is hampered when patients must travel a distance for surgical care. In recent years there has been increasing interest in patient-generated health data (PGHD) that includes patients taking photographs of their surgical incisions. Methods: A selective review of articles on PGHD and photographic images was undertaken in combination with interviews of investigators in this field. Results: There is a possibility that a well-developed system to facilitate patient-provided images of the surgical incision to surgical care providers in a Health Insurance Portability and Accountability Act (HIPAA)-compliant manner could improve surgical surveillance and reduce unnecessary post-operative visits. Conclusions: Further study is required.

Implementation of the small bites closure of abdominal midline incisions in clinical practice is correlated with a reduction in surgical site infections.

Small steps wound closure of midline laparotomy has been reported to decrease the incidence of incisional hernia development in two randomized controlled trials. The aim of the present study was to evaluate the effect of implementing the small steps wound closure technique in clinical practice with regards to the development of incisional ventral hernia (IVH) and surgical site infections (SSI) in clinical practice. Implementation of the small steps wound closure technique using the small tissue bites technique as the standard closure technique for abdominal midline incisions in our clinical practice was done in March 2015. For this study, all patients from June 2013 until June 2016 with a midline laparotomy, either long or small in case of specimen extraction in laparoscopic surgery, in either elective or emergency setting were included. Conventional large bite wound closure was compared to small steps wound closure with regards to the development of SSI, IVH as well as burst abdomen. A total of 327 patients were included. The small steps suture technique was used in 136 (42%) of the patients, whereas the conventional large bites suture technique was used in 191 patients (58%). A total of 54 patients in the large bites group developed SSI (28%) compared to 23 (17%) patients in the small steps group (p = 0.02). A total number of 10 patients (7%) developed IVH in the small steps group compared to 27 patients (14%) in the large bites group (p = 0.08). Implementation of small bites wound closure of abdominal midline incisions in clinical practice was correlated with a reduction in surgical site infections.

Gentamicin-impregnated collagen implants for the reduction of surgical site infections

Gentamicin-impregnated collagen implants for the reduction of surgical site infections

Reduction in Surgical Site Infections Through Obstetrics–Surgical Services Collaboration

St. Jude Medical Center had always enjoyed excellent patient outcomes. However, it was noted that during a 1-year period, there was a rise in the infection rate for cesareans and this was cause for concern. It was discovered that there could be several variables causing the rise in infections, and a plan for education in surgical asepsis was designed to decrease the risk of infection to patients. It was identified that customs and practices that existed in the labor and delivery unit would benefit from a formal review of the structure and processes of surgical aseptic technique. An educational practicum was designed and implemented to provide basic instruction and practice in the perioperative environment. The obstetrics and surgical services departments collaborated to create a program that addressed the knowledge gap caused by lack of consistent perioperative nursing training among the labor and delivery unit nursing staff. Perioperative nurses who had completed preceptorship training were selected and paired with their labor and delivery unit counterparts. Each labor nurse completed a minimum of 16 hours of direct instruction in the main operating room (OR) prior to validation during a cesarean birth. Thirty labor and delivery unit nurses and scrub technologists have completed OR rotations and achieved competency, as documented by the competency validation checklist. This has resulted in a significant decrease in cesarean infections as well as an increased number of personnel available to provide care for women undergoing an emergency cesarean. Since its implementation, the rates of infection and foreign body retention have decreased significantly, and the collaboration between the two departments has resulted in improved patient outcomes. In addition, a complicated, life-threatening cesarean birth was carried out successfully due to the finely honed collaboration between the surgical services and obstetrics departments. By identifying knowledge gaps in perioperative nursing practice, the risk of developing a surgical site infection was significantly decreased.

Integrating the ACS-NSQIP SSI bundle into a colorectal ERAS pathway for optimal SSI reduction

Objectives: Enhanced Recovery After Surgery (ERAS) pathways and the ACS-NSQIP surgical site infection (SSI) bundles are proven to reduce SSI in colorectal surgery patients. VCU Health aimed to combine both of these intervention bundles to reduce SSI to the lowest possible rate. In doing so we also reviewed the evidence base for each individual ERAS intervention for their impact on SSI.

Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events

The benefits of antimicrobial prophylaxis are limited to the first 24 hours postoperatively. Little is known about the harms associated with continuing antimicrobial prophylaxis after skin closure. To characterize the association of type and duration of prophylaxis with surgical site infection (SSI), acute kidney injury (AKI), and Clostridium difficile infection. In this multicenter, national retrospective cohort study, all patients within the national Veterans Affairs health care system who underwent cardiac, orthopedic total joint replacement, colorectal, and vascular procedures and who received planned manual review by a trained nurse reviewer for type and duration of surgical prophylaxis and for SSI from October 1, 2008, to September 30, 2013, were included. Data were analyzed using multivariable logistic regression, with adjustments for covariates determined a priori to be associated with the outcomes of interest. Data were analyzed from December 2016 to December 2018. Duration of postoperative antimicrobial prophylaxis (<24 hours, 24-<48 hours, 48-<72 hours, and ≥72 hours). Surgical site infection, AKI, and C difficile infection. Of the 79 058 included patients, 76 109 (96.3%) were men, and the mean (SD) age was 64.8 (9.4) years. Among 79 058 surgical procedures in the cohort, all had SSI and C difficile outcome data available; 71 344 (90.2%) had AKI outcome data. After stratification by type of surgery and adjustment for age, sex, race, diabetes, smoking, American Society of Anesthesiologists score greater than 2, methicillin-resistant Staphylococcus aureus colonization, mupirocin, type of prophylaxis, and facility factors, SSI was not associated with duration of prophylaxis. Adjusted odds of AKI increased with each additional day of prophylaxis (cardiac procedure: 24-<48 hours: adjusted odds ratio [aOR], 1.03; 95% CI, 0.95-1.12; 48-<72 hours: aOR, 1.22; 95% CI, 1.08-1.39; ≥72 hours: aOR, 1.82; 95% CI, 1.54-2.16; noncardiac procedure: 24-<48 hours: aOR, 1.31; 95% CI, 1.21-1.42; 48-<72 hours: aOR, 1.72; 95% CI, 1.47-2.01; ≥72 hours: aOR, 1.79; 95% CI, 1.27-2.53). The risk of postoperative C difficile infection demonstrated a similar duration-dependent association (24-<48 hours: aOR 1.08; 95% CI, 0.89-1.31; 48-<72 hours: aOR, 2.43; 95% CI, 1.80-3.27; ≥72 hours: aOR, 3.65; 95% CI, 2.40-5.53). The unadjusted numbers needed to harm for AKI after 24 to less than 48 hours, 48 to less than 72 hours, and 72 hours or more of postoperative prophylaxis were 9, 6, and 4, respectively; and 2000, 90, and 50 for C difficile infection, respectively. Vancomycin receipt was also a significant risk factor for AKI (cardiac procedure: aOR, 1.17; 95% CI, 1.10-1.25; noncardiac procedure: aOR, 1.21; 95% CI, 1.13-1.30). Increasing duration of antimicrobial prophylaxis was associated with higher odds of AKI and C difficile infection in a duration-dependent fashion; extended duration did not lead to additional SSI reduction. These findings highlight the notion that every day matters and suggest that stewardship efforts to limit duration of prophylaxis have the potential to reduce adverse events without increasing SSI.

Effect of surgical safety checklist on colorectal surgical site infection rates in 2 countries: Brazil and Canada

The effectiveness of the surgical safety checklist (SSC) in countries with different socioeconomic backgrounds is uncertain. To evaluate the effect of the SSC in 2 different socioeconomic settings, we compared surgical site infection (SSI) rates before and after its implementation in colorectal procedures. An epidemiological retrospective study was conducted in the university hospitals in Ottawa, Canada, and Belo Horizonte, Brazil. Data were collected through chart review from the period before and after the SSC implementation. The SSI rate decreased from 27.7%-25.9% (P = .625) and from 17.0%-14.4% in Canada and Brazil, respectively (P = .448) after the SSC implementation. In Canada, there was no SSI in incomplete SSC, and in Brazil, SSI was 20.0% (P = .026). Despite high and regular completion of the SSC in the Canadian and Brazilian hospitals, respectively, there was no significant reduction of SSI after the SSC implementation in any setting. However, in Brazil, the association between incomplete SSC and higher SSI rates demonstrated the potential impact of the SSC in developing countries. The effect of the SSC on SSI may be greater in developing countries due to minor investment and consolidation of policies in SSI prevention.

IMPACT OF ORAL ANTIBIOTIC PROPHYLAXIS ON SURGICAL SITE INFECTION AFTER RECTAL SURGERY: RANDOMIZED CONTROLLED TRIAL

AIM: to evaluate the efficacy of preoperative oral antibiotics in reduction of surgical site infection (SSI) in rectal surgery. METHODS: patients undergoing rectal resection were assigned randomly to 2 groups: control (standard preoperative care and intravenous injection of 3d generation cephalosporin) and oral antibiotics group (the above was complemented by three-knit oral metronidazole 500 mg and erythromycin 500 mg after beginning of mechanical bowel cleansing at 5.00, 8.00 and 10.00 p.m.). The primary endpoint was the overall rate of SSI. RESULTS: between November 2017 and October 2018, 104 patients (48 in the oral antibiotics group and 56 in control group) were enrolled for this study. The incidence of SSIs was 19.6% (11/56) in control group and 4.1% (2/48) in the oral antibiotics group(р=0.01). Both groups had no statistically significant differences in intensity of SSIs and rate of anastomotic leakage. CONCLUSION: preoperative oral antibiotic significantly reduced the risk of SSIs following rectal surgery. The study needs to be continued for evaluation of preoperative oral antibiotics impact to intensity of SSIs and rate of anastomotic leakage.

A comparative study to test the effectiveness of triclosan coated polyglactin 910 in reduction of surgical site infection in clean wounds

Background: Surgical site infection (SSI) has been pointed out as the 2nd most common nosocomial infection. Since suture materials have been proven to be a contributor to SSI, they have been the focus of research and development centered on making them less conducive to bacterial overgrowth. The Triclosan coated suture slowly releases Triclosan, which is an antibacterial agent that inhibits bacterial colonization of the suture and wound site and thus, promises prevention of surgical site infection.Methods: Total of 100 patients undergoing excision of uninfected subcutaneous benign lumps and cutaneous swellings were randomized in two groups: group A in which triclosan coated polyglactin 910 suture was used for wound closure (50 patients) and Group B in whom conventional uncoated Polyglactin 910 suture was used for wound closure (50 patients).Results: In this study, maximum number of patients was in the age group of 46-60 years. Mean age of subjects in triclosan- coated suture group was 45.03 years while it was 47.32 in conventional uncoated suture group. Among 100 subjects in triclosan- coated suture group, 26 (52%) were males and 24 (48%) were females. In comparison to it, male and female subjects in conventional uncoated suture group were 25 (50%) each. Among 50 subjects in triclosan- coated suture group, only 2 (4.0%) had surgical site infection while in conventional uncoated suture group, 8 (16.0%) had surgical site infection. Incidence of surgical site infection with use of triclosan- coated suture was significantly lower compared to conventional uncoated suture group. (p 0.04).Conclusions: Triclosan coated suture surely, helps in preventing surgical site infection which, not only increases the morbidity of the patient but also has long-term implications.

Oral antibiotic preparation in colorectal surgery: is there more to debate?

The use of non-absorbable oral antibiotic preparation (OAB) in colorectal surgery was first proposed by Rosenberg and colleagues in 1971 (1), who in their randomised controlled trial (RCT) of combined mechanical bowel preparation (MBP) and one (phthalylsulphathiazole) or two oral antibiotics (phthalylsulphathiazole and neomycin) found a significant reduction in surgical site infection (SSI) and anastomotic leak rates in a population of patients undergoing large bowel surgery after combined OAB and MBP when compared with those who received MBP alone.

Pattern of antimicrobial usage for prophylaxis of surgical site infection in a tertiary care hospital of Western Uttar Pradesh

Background: The practice of giving antibiotic prophylaxis has resulted in the reduction of surgical site infections (SSI), thus reducing cost, morbidity, and mortality. Common nosocomial infections in surgical patients include SSIs, urinary tract infections (UTIs), pneumonias and blood stream infections (BSIs). The present study was, therefore, designed to analyze the efficacy of antimicrobials used for prophylaxis during surgery in a tertiary care hospital in India.Methods: Total 100 patients were enrolled. Name, timing, route, dose of antimicrobials given were recorded. All the relevant data was taken from the patient’s medication charts and medical records. Chi-square test and t-test were applied.Results: The optimal time of giving antimicrobial prophylaxis in present study was 1 hour before the surgery. A total of 8 different antimicrobials were prescribed to 100 patients, out of which most commonly prescribed were cephalosporin i.e. 82%. Majority of SSI (57.12%) occurred when the duration of surgical antimicrobial prophylaxis (SAP) was for ≥2 hours (p value &lt;0.05). Common organisms seen in SSI were E. coli, S. aureus, Pseudomonas and Kleibsella species. The hospital stay of patients with SSI was more as compared to patients without SSI in present study (p value &lt;0.05).Conclusions: It has been observed that inappropriate selection and timing of giving SAP play an important role in developing SSI, which can be adequately controlled by adopting SAP guidelines, good infection control practices and risk factor analysis.

Antibiotic prophylaxis: current recommendations in plastic surgery

Guidelines for prophylactic antibiotics in surgery have long been established; however, few have focused on recommendations in plastic surgery. Surgical site infection rates remain low, yet the use of prophylactic antibiotics has surged in the past 30 years. This article summarizes current recommendations of prophylactic antibiotic use to produce consensus guidelines in plastic surgery. A literature review was conducted in the PubMed, Cochrane, and Ovid databases and studies were included if randomized controlled trials indicated a statistically significant decrease in surgical site infections. Surveys conducted by the American Society of Plastic Surgeons regarding prophylactic antibiotic use from 1975, 1985, 2000, and 2010 were compiled and analyzed. Of 143 articles found, nine randomized controlled trials showed a reduction in surgical site infections after antibiotic prophylaxis for specific plastic surgery procedures. There are evidence-based recommendations for prophylactic antibiotics in breast surgery, abdominoplasty, contaminated hand or face surgery, prosthetic surgery, rhinoplasty, microsurgery, and acute and burn reconstruction cases. The proportion of plastic surgeons using prophylactic antibiotics has steadily increased from 1975 to 2010 with a significant increase from 2000 to 2010. Systemic antibiotic prophylaxis is recommended for use in breast surgery, abdominoplasty, contaminated hand or face surgery, prosthetic surgery, rhinoplasty, microsurgery, and acute and burn reconstruction cases. Recent surveys indicate that the majority of plastic surgeons continue to use prophylactic antibiotics in clean cases of the hand, face, and body despite recommendations. Additional procedure-specific randomized controlled trials are necessary to provide evidence-based recommendations for antibiotic prophylaxis in plastic surgery. Level of Evidence: Level IV, risk / prognostic study

Preoperative Chlorhexidine Gluconate Scrub Shower for Inpatient Vascular Patients: A Quality Improvement Project

The etiology of surgical site infection (SSI) is multifactorial, with efforts to combat it employing "bundled" initiatives. Preoperative antiseptic wash was classified by the Centers for Disease Control and Prevention as a Category IB strongly recommended and accepted practice. Its inclusion, in a best-practice bundle, may contribute to reduction in SSIs. We describe our quality improvement initiative to increase adherence to this critical bundle element.

Implementation of a restrictive blood transfusion protocol in a gynecologic oncology service.

The purpose of this study was to evaluate the impact of a restrictive blood transfusion protocol in a postoperative gynecologic oncology population. The primary objective was the rate of blood transfusions after surgery before and after implementation of a restrictive transfusion protocol (from July 1st 2011 to December 30th 2016). Secondary outcomes were patient morbidity and included rates of surgical site infection, pneumonia, sepsis, unplanned intubation, prolonged ventilator use, renal insufficiency, acute renal failure, urinary tract infection, cerebral vascular accident, cardiac complications, venous thromboembolism, and death within 30 days of surgery, readmissions and length of stay. A restrictive blood transfusion protocol was implemented by the gynecologic oncology service at a National Comprehensive Cancer Network designated Comprehensive Cancer Center on January 1st, 2014. The restrictive protocol required that no patient receive a blood transfusion for hemoglobin greater than 7.0 g/dL (or hematocrit greater than 21.0%) and that all red blood cells were administered in one unit increments followed by re-evaluation of blood parameters. Exceptions to this protocol were postoperative symptomatic anemia, intraoperative or day of surgery transfusion, active bleeding, postoperative severe sepsis, postoperative active coronary ischemia, and postoperative transfusion after 1.5 liter or greater blood loss. 1482 patients were identified for this study (755 in the pre-protocol group and 727 in the post-protocol group). Patients treated under the restrictive protocol had decreased rates of red blood cell transfusion (11.0% vs 5.9% p<0.001), superficial surgical site infection (7.7% vs 4.1% p=0.005), deep surgical site infection (2.3% vs 0.7% p=0.02), and median length of stay (3.0 days vs 2.0 days p<0.001). A restrictive blood transfusion protocol is associated with reductions in the rates of blood transfusions and postoperative morbidity with a 46.8% reduction in superficial surgical site infection and a 69.6% decrease in deep surgical site infection in the gynecologic oncology patient population.