pregnant women are at risk of 
 infection during labor and delivery ; most infections 
 of the female pelvic 
 organs occur when normal flora of the female 
 genital or gastrointestinal tract 
 contaminate the normally sterile amniotic fluid and uterus . 
 these bacteria can 
 become pathogenic , particularly in devitalized tissue 
 . 

 bacterial infections in pregnant women may 
 also originate from inoculation of bacteria during 
 childbirth or surgery or 
 from hematogenous spread . uterine infections are much more common after cesarean 
 delivery ( c - section ) than following a vaginal delivery 
 . fortunately , 
 postpartum or puerperal infections have 
 decreased over the last hundred years 
 due to improved procedures and effective 
 antibiotic use . however , infections 
 still cause about 13% of pregnancy - related deaths 
 and are the fifth leading 
 cause of death among this population 
 . group a streptococcus ( gas ) , or 
 streptococcus pyogenes , is an uncommon , 
 but serious and potentially preventable cause of 
 postpartum and postsurgical infections . the 
 incidence of confirmed gas 
 infections among deliveries in a study in jerusalem over 6.5 
 years ranged from 0.33 to 3.16 per 1000 births ; 
 suspected intra- or postpartum gas infections 
 occurred in 13.2% of all deliveries 
 . 
 in a review of records of all mothers and 
 babies with gas bacteremia in 
 the united kingdom from 19801999 , peripartum 
 gas infection occurred in 1 of every 11,000 live 
 births . the source of a sporadic postpartum gas infection is typically 
 unknown , but outbreaks of postpartum and 
 postsurgical gas infections have been 
 associated with colonized healthcare workers . healthcare workers who were 
 asymptomatic carriers of gas have been identified in 
 15 of 21 outbreaks of 
 postpartum and postsurgical infections reported from 
 1976 through 2005 [ 626 ] ; 
 these infections represent a preventable manifestation 
 of severe gas disease . in 2002 , centers for disease control ( cdc ) 
 published guidelines for prevention of 
 secondary invasive gas infections , including 
 those among postpartum and postsurgical 
 patients . 
 recommended strategies for the investigation of both a single 
 case and clusters of postpartum or postsurgical gas 
 infection were developed . 
 in brief , a single healthcare - associated infection 
 should trigger notification 
 of the hospital infection control practitioner , 
 enhanced surveillance for 
 additional cases and storage of gas patient isolates 
 for potential strain 
 characterization . when two or more postpartum or 
 postsurgical cases occur in 
 the same healthcare facility within six months , 
 cdc recommends that 
 epidemiologic links between the cases be 
 investigated , including screening for 
 gas colonization of healthcare personnel linked to known cases . although these guidelines were published 
 in 2002 , the level of awareness and adherence 
 to these recommendations is 
 unknown . also , clinician knowledge and management 
 of pregnancy - related and postsurgical 
 infections has not been assessed . we conducted a survey of obstetric 
 and gynecologic providers ( ob / gyns ) to estimate 
 the frequency of intrapartum , 
 postpartum , and postsurgical infections they 
 encounter to determine bacterial 
 culturing practices among providers , and to 
 estimate the frequency of gas 
 isolation among the respondents patient populations . we also sought to estimate awareness and 
 adherence to the cdc guidelines , assess 
 barriers to follow the guidelines , and 
 query providers regarding more effective 
 methods for distributing these 
 recommendations . in july 2005 , an anonymous questionnaire 
 focusing on current practices regarding intrapartum , 
 postpartum , and postsurgical 
 infections was mailed to 1300 american 
 college of obstetricians and 
 gynecologists ( acog ) fellows and junior fellows in practice ; 
 1000 subjects were 
 members of the collaborative ambulatory research 
 network ( carn ) . members 
 of carn are practicing ob / gyns who have volunteered 
 to participate regularly in 
 surveys , facilitating assessment of clinical 
 practice patterns , and aiding 
 development of educational materials . the remaining 300 subjects 
 consisted of a computer - generated random sample 
 of acog fellows and junior 
 fellows in practice who are practicing 
 obstetrics and/or gynecology and had not 
 received a survey from acog during the previous 
 two years ( non - carn ) . a second 
 mailing was sent approximately five weeks after 
 the first to those individuals 
 who did not initially respond . all survey respondents who reported 
 performing deliveries or surgeries in 2004 were 
 eligible for inclusion in our analysis . the survey included questions about the 
 practitioner 's age and training , his / her 
 practice , patient population demographics , 
 and specific questions assessing 
 experience with diagnosing and treating intrapartum , 
 postpartum ( e.g. , wound 
 infections , endometritis , bacteremia ) , and postsurgical 
 infections ( e.g. , wound 
 infections , endometritis , vaginal cuff cellulitis , 
 bacteremia ) , particularly 
 infections potentially due to gas . survey respondents were asked to estimate the racial and ethnic 
 distributions of their patient population , 
 number of deliveries and surgeries 
 performed and related infections seen during 2004 . questions also assessed the 
 practitioner 's use and understanding of the 
 cdc guidelines for prevention of 
 gas infections among postpartum and postsurgical patients . survey responses were double - entered into 
 an american standard code for information 
 interchange ( ascii ) file , corrected for data 
 entry errors , and converted into an 
 sas 9 database ( sas institute , cary , nc , usa ) . the racial and ethnic 
 characteristics of the provider 's patient 
 population were dichotomized into the 
 following categories , based on the distribution 
 of responses : less than 80% white versus 80% or more white ; 
 less than 25% versus 25% or more black ; 
 less than 20% versus 20% or more 
 hispanic ; less than 7% versus 7% or more asian / pacific 
 islander . the percentage 
 of patients with medicaid was divided into low 
 ( < 25% ) , medium ( 2549% ) , and 
 high ( 50% ) categories . comparisons of responses by carn and 
 non - carn members were completed for all survey 
 questions . all statistically 
 significant differences between carn and non - carn are 
 presented ; otherwise the 
 results for both carn and non - carn combined are shown . completed surveys were returned by 614 ( 61% ) carn and 75 
 ( 24% ) non - carn members ( 53% of all respondents ) . respondents who had not 
 performed deliveries or surgeries in 2004 ( 54 carn 
 and 6 non - carn respondents ) 
 were excluded . demographic and practice 
 characteristics of the remaining 629 
 survey respondents are detailed in table 
 1 . a majority 
 of respondents practiced 
 in a group setting , worked in an urban or suburban 
 location , and considered 
 themselves specialists . members of carn 
 were older and more likely than 
 nonmembers to be male and to have been in 
 practice for 10 or more years . significant differences in sex of the 
 respondents and number of years in 
 practice among carn versus non - carn members did 
 not persist when controlling 
 for age : age and years of experience were 
 highly correlated ( pearson 
 correlation coefficient , r=0.91 ; p<.0001 ) . nearly all providers performed both 
 deliveries ( vaginal or cesarean ) ( 91% ) and 
 surgeries ( hysterectomies or cesarean 
 deliveries ) ( 96% ) in the year preceding the survey . 
 based on respondents 
 estimates , the median number ( and range ) 
 of vaginal deliveries performed per 
 provider in 2004 were 120 ( 4512 ) 
 ( n=568 survey respondents ) , and a median of 
 55 ( range : 1450 ) surgeries were performed per provider 
 in 2004 ( n=596 respondents ) . based on respondents ' estimates , the median number of patients 
 ( per provider ) who developed intraamniotic 
 infection or chorioamnionitis in the year 
 preceding the survey was five ( range : 0100 ) . 
 nearly all respondents ( 91% of 568 ) stated that they would treat an 
 intraamniotic infection empirically , without 
 obtaining a complete blood count 
 or blood culture or waiting for the results of 
 either test if obtained . over half of respondents believe that the most common bacterial cause of 
 intraamniotic infections is polymicrobial ( table 2 ) . with increasing years of 
 experience , providers were more likely to 
 consider gram - negative rods the most 
 common bacterial cause of intraamniotic 
 infections and less likely to consider 
 the cause polymicrobial in origin ( chi - square test for linear 
 trend : p < .001 for each ) . per survey respondents , an 
 estimated 3% of patients who had vaginal deliveries developed a postpartum 
 infection , and 7% of patients undergoing surgery ( cesarean delivery or hysterectomy ) 
 developed postsurgical infections . over half of providers stated that they do 
 not obtain diagnostic specimens from their patients with postpartum infections ; 
 only 14% always obtain specimens . providers with increasing 
 years of experience were more likely to routinely obtain specimens for 
 microbiological diagnosis of postpartum infections ( chi - square test for 
 linear trend : p=.002 ) . those who considered themselves both primary 
 care physicians and specialists were more likely to routinely obtain cultures 
 than respondents who considered 
 themselves specialists only ( 21% versus 10% ; p<.001 ) . the 
 suspected frequency of staphylococcus aureus 
 and group b streptococcal 
 infections differed for postpartum compared to 
 postsurgical infections ( table 2 ) . in general , more providers either 
 always ( 18% ) or sometimes ( 52% ) obtained 
 cultures from patients with postsurgical 
 infections compared to those with postpartum 
 infections ; only 30% empirically 
 treated without obtaining specimens . providers with 
 increasing years of 
 experience were more likely to always obtain 
 specimens from patients with postsurgical 
 infections ( chi - square test for linear trend : 
 p=.004 ) . as with 
 postpartum infections , those respondents who considered themselves both primary 
 care providers and specialists were more likely to routinely obtain specimens 
 than those who considered themselves specialists ( p=.001 ) . when asked 
 to estimate how many of their 
 patients developed a postpartum infection or a 
 postsurgical infection that was 
 caused by gas in the previous year , 384 and 472 providers responded , 
 respectively . the numbers of estimated 
 gas - specific infections for all 
 providers combined were 81 postpartum and 81 
 postsurgical gas infections . when gas is isolated during routine 
 rectovaginal culture for group b streptococcus 
 ( gbs ) , 9% of respondents stated that they would treat the patient with 
 antibiotics , 15% would give intrapartum antibiotic 
 prophylaxis similar to 
 management of gbs , most respondents ( 64% ) would do nothing , 
 and 8% stated that 
 they either do not see this organism or their 
 laboratory does not routinely 
 test rectovaginal cultures for gas . the majority of survey respondents 
 correctly indicated that each of the five body 
 sites listed ( oropharynx , nares , 
 rectum , vagina , and skin ) may be colonized 
 by gas ( table 3 ) although less than 
 half ( 47% ) chose all five 
 sites . respondents chose the following as possible 
 causes of a cluster of 
 postpartum or postsurgical gas infection in a facility : 
 healthcare worker is a gas carrier ( 44% 
 respondents ) ; patient being colonized prior to 
 delivery or surgery ( 28% ) ; as 
 well as poor infection control practices ( 23% ) . answers given to questions 
 about potential sites of gas colonization and 
 possible causes of clusters did 
 not vary by provider characteristics such as 
 years in practice or practice 
 type . when questioned about action taken when a postpartum or postsurgical gas infection 
 is identified , 25% would contact infection control personnel . few 
 respondents chose the other two 
 actions recommended in the cdc guidelines 
 ( save gas isolates for further study ; 
 enhance surveillance for such infections ) 
 ( table 3 ) . the majority ( 73% ) of 
 respondents stated that they had not diagnosed 
 any gas infections . the proportion of respondents who would take 
 actions recommended in the guidelines 
 increased with increasing years in practice ; 
 the proportion was also higher among providers 
 with practices in rural areas . few survey respondents correctly identified 
 the number of postpartum or postsurgical 
 gas infections that should trigger infection 
 control notification and investigation 
 if the infections occurred in the same facility 
 within six months : 23% stated correctly that two such infections 
 should elicit this response 
 ( table 3 ) . carn members ( 26% ) more frequently chose 
 this response than non - carn members 
 ( 4% ; p<.01 ) . no significant 
 associations between choosing the 
 correct response and other provider 
 characteristics ( i.e. , years in practice , 
 practice type or location ) were 
 noted . only 5.6% of respondents ( n=611 ) 
 stated that they were familiar with the 
 2002 cdc guidelines for management of 
 gas infections ; in fact , over 70% were 
 unaware of their existence . other 
 barriers to learning about or following the 
 guidelines included : perceived 
 infrequency of gas infections in the respondent 's practice 
 ( 18% ) , publication 
 in a journal not routinely read ( 13% ) , the fact that 
 the provider does not 
 consider gas infection a priority disease ( 9% ) , 
 and a lack of culture results 
 for postpartum and postsurgical infections ( 4% ) . most ( 74% ) respondents stated 
 that they do follow guidelines regarding diagnostic , 
 management , or treatment 
 of postpartum and postsurgical infections , 
 principally those by acog ( 59% ) and 
 those which are part of hospital infection control protocols ( 32% ) . our study is the first published 
 survey of the knowledge , attitudes , and practices of 
 ob / gyns regarding the 
 perceived frequency , etiology , and management 
 of intrapartum , postpartum , and postsurgical 
 infections . among a large number of ob / gyns , 
 we found that most empirically 
 treat a variety of infections encountered in 
 their routine practice . although 
 this approach is within current standards of care , 
 this presents a missed 
 opportunity for the identification and potential 
 prevention of illnesses such 
 as severe gas infections . both our survey and the current 
 literature suggest that intraamniotic , postpartum , and 
 postsurgical infections 
 are not uncommon . the providers in our survey 
 identify approximately three 
 postpartum infections per 100 vaginal deliveries 
 and 7 postsurgical infections 
 per 100 cesarean deliveries and hysterectomies . these estimates are 
 conservative , as they do not include deliveries 
 by other providers ( e.g. , 
 family practitioners ) , but are consistent with 
 previous estimates in the literature . intraamniotic infections have been reported to range 
 from 0.5% to 10.5% of all 
 pregnancies , occurring in 15% of term pregnancies 
 and up to 10% in patients 
 with premature labor [ 2832 ] . puerperal 
 or postpartum endometritis has been reported to 
 occur in 13% of women with 
 vaginal deliveries and among 515% of women 
 having scheduled repeat cesarean 
 deliveries [ 1 , 28 ] . nearly all survey respondents treat 
 intrapartum , postpartum , and postsurgical 
 infections empirically although 
 providers are more likely to obtain diagnostic 
 specimens from patients with postsurgical 
 infections . while no formalized guidelines on diagnostic management of 
 intrapartum and postpartum infections exist , 
 empiric therapy is not contrary to 
 current practice recommendations . recently 
 developed acog guidelines on the use 
 of prophylactic antibiotics in labor and delivery recommend the use of 
 prophylactic antibiotics in both high- and low - risk 
 patients undergoing cesarean 
 delivery although the data to support use among low - risk patients is 
 inconclusive . blood cultures are 
 typically taken only when the patient does not 
 respond to empiric antibiotics 
 or if complications arise . the rationale for not obtaining diagnostic 
 cultures is multifold ; antibiotic therapy is 
 typically empiric and based on 
 clinical diagnosis , patients often respond to 
 antibiotics before culture 
 results are known , anaerobes are notoriously 
 difficult to isolate , accurate 
 postpartum endometrial specimens are difficult 
 to obtain because of possible 
 contamination by the lower genital tract , 
 and cultures add cost and time . conversely , pretreatment cultures 
 facilitate management of patients who fail initial 
 empiric antibiotic . investigations of the specific 
 pathogens causing intraamniotic , 
 postpartum , and postsurgical infections have 
 shown that the primary causative 
 agents change over time . for example , the principal 
 etiology of early onset 
 neonatal sepsis has ranged from gas in the 
 1930s1940s , e. coli in the 
 1940s1970s , to group b streptococci in the 
 current era . also , recent studies have documented an increase in the 
 proportion of healthcare - associated bloodstream 
 infections and the emergence of 
 community - associated methicillin - resistant 
 staphylococcus aureus infections among 
 pregnant and postsurgical patients 
 [ 3840 ] . comprehensive 
 studies to evaluate the etiologies of pregnancy - related 
 infections have not 
 been performed for over 15 years [ 4145 ] . periodic evaluations of the etiologies 
 of pregnancy - related infections and the 
 prevalence of antibiotic - resistant 
 isolates among this population would be useful . another benefit of obtaining pretreatment 
 cultures is that identification of certain 
 pathogens , such as gas , should 
 trigger specific infection control measures to 
 prevent spread of disease . gas 
 infections can be devastating with an overall case 
 fatality ratio ( cfr ) of 13% 
 and cfrs of 2536% for the most 
 severe manifestations  necrotizing 
 fasciitis and streptococcal toxic shock syndrome 
 . because we only 
 surveyed ~3% of the nation 's ob / gyns , 
 we estimate that as many as 2700 
 postpartum and 2700 postsurgical gas infections 
 may occur annually in the united states . healthcare - associated transmission of 
 gas infections can sometimes be prevented , 
 for example , in instances where an 
 asymptomatic colonized healthcare worker is 
 identified and treated as a result 
 of a thorough epidemiologic investigation 
 . provider responses to the 
 gas - specific questions included in our survey 
 underscore both the lack of 
 awareness of the cdc gas guidelines among one 
 of their targeted audiences very few 
 providers were aware of the 
 guidelines and the recommended public 
 health action following identification of 
 postpartum and postsurgical gas infections . 

 the principal reason for not 
 understanding or following these guidelines was a 
 lack of awareness of their existence , 
 most likely because they were published in a 
 journal not read by this group of 
 providers . potential solutions to this 
 dilemma include publication in journals 
 relevant to ob - gyns , incorporation into 
 acog guidelines and hospital infection 
 control protocols , presentation at relevant 
 meetings , and inclusion in cme 
 lecture series . a common thread in our survey 
 results is the association of increasing 
 years of experience and older age with 
 a variety of practice patterns . older , 
 more experienced providers were far more 
 likely to attempt to determine the etiology of 
 intra- and postpartum infections 
 and also had different beliefs from younger 
 providers as to the specific 
 etiologies of such infections.the 
 reasons for these trends are 
 unknown but may include changes in medical 
 education or in the epidemiology of these infections . limitations of our survey include 
 our low response rate , particularly among 
 non - carn providers although it is 
 consistent with other acog surveys 
 [ 47 , 
 48 ] . an important 
 limitation is that we were unable to 
 validate the estimated number of 
 procedures performed and actual practices 
 reported by the respondents . it is 
 possible that the frequencies of infections 
 reported are significantly 
 underestimated . also , given the low number of 
 providers who were aware of the cdc 
 guidelines for postpartum and postsurgical 
 gas infections , attempts to estimate 
 the respondents ' understanding of specific 
 aspects of these guidelines are of 
 limited value . in summary , although the use of 
 empiric antibiotics in intraamniotic , postpartum , 
 and postsurgical infections 
 may currently be effective in most cases , 
 the paucity of diagnostic cultures 
 obtained presents a missed opportunity to 
 monitor the etiology of these 
 infections and to identify a potentially 
 preventable cause of serious healthcare - associated 
 disease  gas infections . current efforts to educate providers regarding 
 the settings in which the 
 identification of gas should trigger a 
 public health response and augment 
 infection control practices are inadequate . 
 however , our survey identified more 
 effective means of communicating with practicing 
 ob / gyns and also emphasized 
 that educational efforts should target the 
 infection control practitioner ( icp ) 
 as most hospitals currently rely on the icp to 
 identify potential healthcare - associated 
 infections and initiate necessary investigations . periodic , time - limited 
 studies of the etiologies of pregnancy - related 
 infections by public health and 
 clinical researchers would help to monitor changes 
 in the principal pathogens , 
 track trends in antimicrobial resistance , and guide 
 clinical management .