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Accessible version: i/index.htmlGuidelines for the Prevention ofIntravascular Catheter-RelatedInfections, 2011Naomi P. O'Grady, M.D.1, Mary Alexander, R.N.2, Lillian A. Burns, M.T., M.P.H., C.I.C.3, E. PatchenDellinger, M.D.4, Jeffery Garland, M.D., S.M.5, Stephen O. Heard, M.D.6, Pamela A. Lipsett,M.D.7, Henry Masur, M.D.1, Leonard A. Mermel, D.O., Sc.M.8, Michele L. Pearson, M.D.9, Issam I.Raad, M.D.10, Adrienne Randolph, M.D., M.Sc.11, Mark E. Rupp, M.D.12, Sanjay Saint, M.D.,M.P.H.13 and the Healthcare Infection Control Practices Advisory Committee (HICPAC)14.12345678910111213National Institutes of Health, Bethesda, MarylandInfusion Nurses Society, Norwood, MassachusettsGreenich Hospital, Greenwich, ConnecticutUniversity of Washington, Seattle, WashingtonWheaton Franciscan Healthcare-St. Joseph, Milwaukee, WisconsinUniversity of Massachusetts Medical School, Worcester, MassachusettsJohns Hopkins University School of Medicine, Baltimore, MarylandWarren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode IslandOffice of Infectious Diseases, CDC, Atlanta, GeorgiaMD Anderson Cancer Center, Houston, TexasThe Children's Hospital, Boston, MassachusettsUniversity of Nebraska Medical Center, Omaha, NebraskaAnn Arbor VA Medical Center and University of Michigan, Ann Arbor, MichiganUpdated Recommendations [July 2017]:See the Updated Recommendations on the Use of Chlorhexidine-Impregnated Dressingsfor Prevention of Intravascular Catheter-Related uidelines/bsi/c-i-dressings/index.html)Content Removed [October 2017]Content in the Notice to Readers section was removed to reflect the recommendationupdate and the evolution of CDC infection control guideline methodology.Last update: October 2017Page 1 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)4Healthcare Infection Control Practices Advisory CommitteeCHAIRMANEXECUTIVE SECRETARYBRENNAN, Patrick J., MDChief Medical OfficerDivision of Infectious DiseasesUniversity of Pennsylvania Health SystemBELL, Michael R., MDDeputy DirectorDivision of Healthcare Quality PromotionCenters for Disease Control and PreventionMEMBERSHIPBRATZLER, Dale, DO, MPHPresident and CEOOklahoma Foundation for Medical QualityOSTROFF, Stephen, MDDirector, Bureau of EpidemiologyPennsylvania Department of HealthBURNS, Lillian A., MT, MPHInfection Control CoordinatorGreenwich Hospital, Infectious DiseasesDepartmentOLMSTED, Russell N., MPH, CICEpidemiologistInfection Control ServicesSt. Joseph Mercy Health SystemELWARD, Alexis, MDAssistant Professor, Pediatrics Infectious DiseasesWashington University School of MedicineDepartment of PediatricsDivision of Infectious DiseasesPEGUES, David Alexander, MDProfessor of Medicine, Hospital EpidemiologistDavid Geffen School of Medicine at UCLAHUANG, Susan, MD, MPHAssistant ProfessorMedical Director, Epidemiology and InfectionPreventionDivision of Infectious DiseasesUC Irvine School of MedicineLUNDSTROM, Tammy, MD, JDChief Medical OfficerProvidence HospitalMCCARTER, Yvette S., PhDDirector, Clinical Microbiology LaboratoryDepartment of PathologyUniversity of Florida Health Science CenterPRONOVOST, Peter J., MD, PhD, FCCMDirector, Johns Hopkins Quality and SafetyResearch GroupJohns Hopkins Quality and Safety Research GroupSOULE, Barbara M., RN, MPA, CICPractice LeaderInfection Prevention and Control ServicesJoint Commission Resources/Joint CommissionInternationalSCHECTER, William, P., MDProfessor of SurgeryDepartment of SurgerySan Francisco General HospitalMURPHY, Denise M. RN, MPH, CICVice President, Quality and Patient SafetyMain Line Health SystemLast update: October 2017Page 2 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)EX-OFFICIO MEMBERSAgency for Healthcare Research and Quality(AHRQ)BAINE, William B., MDSenior Medical AdvisorCenter for Outcomes and EvidenceCenter for Medicare & Medicaid Services (CMS)MILLER, Jeannie, RN, MPHDeputy Director, Clinical Standards GroupFood and Drug Administration (FDA)MURPHEY, Sheila A., MDDivision of Anesthesiology, General HospitalInfection Control Dental DevicesCenter for Devices and Radiology HealthNational Institute of Health (NIH)HENDERSON, David, MDDeputy Director for Clinical CareAssociate Director for Hospital Epidemiology andQuality ImprovementNIH Clinical CenterDepartment of Veterans Affairs (VA)ROSELLE, Gary A., MDNational Program Director, Infectious DiseasesVA Central OfficeCincinnati VA Medical CenterLIAISONSAdvisory Council for the Elimination ofTuberculosis (ACET)STRICOF, Rachel L., MPHAmerican College of Occupational andEnvironmental MedicineRUSSI, Mark, MD, MPHProfessor of MedicineYale University School of MedicineDirector, Occupational HealthYale-New Haven HospitalAmerican Health Care Assn (AHCA)FITZLER, Sandra L., RNSenior Director of Clinical ServicesAmerican Hospital Association (AHA)SCHULMAN, Roslyne, MHA, MBADirector, Policy DevelopmentAssociation of Professionals of Infection Controland Epidemiology, Inc. (APIC)DeBAUN, Barbara, MSN, RN, CICAssociation of periOperative Registered Nursed(AORN)BLANCHARD, Joan C., RN, BSNCouncil of State and Territorial Epidemiologists(CSTE)KAINER, Marion, MD, MPHDirector, Hospital Infections and AntimicrobialResistance ProgramTennessee Department HealthConsumers UnionMCGIFFERT, LisaSenior Policy Analyst on Health IssuesProject Director Stop Hospital InfectionsOrganizationInfectious Disease Society of America (IDSA)HUSKINS, W. Charles MD, MScDivision of Pediatric Infectious DiseasesAssistant Professor of PediatricsMayo ClinicPublic Health Agency of CanadaPATON, Shirley, RN, MNSenior Advisor Healthcare Acquired InfectionsCenter for Communicable Diseases and InfectionControlSociety for Healthcare Epidemiology of America(SHEA)MARAGAKIS, Lisa, MDAssistant Professor of MedicineJohn Hopkins Medical InstitutionsSociety of Hospital MedicineSAINT, Sanjay, MD, MPHDirector, Ann Arbor VA Medical Center/Universityof Michigan Patient Safety Enhancement ProgramThe Joint CommissionWISE, Robert A., MDVice PresidentDivision of Standards & Survey MethodsUse of trade names and commercial sources is for identification only and does not imply endorsement by theU.S. Department of Health and Human Services.Last update: October 2017Page 3 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)AcknowledgmentsWe wish to acknowledge Ingi Lee, MD, MSCE and Craig A. Umscheid, MD, MSCE fromCenter for Evidence-based Practice, University of Pennsylvania Health System Philadelphia, PAwho performed a systematic review for issues raised the during the guideline process.Disclosure of potential conflicts of interests. N.P.O.’G. served as a board member forthe ABIM Subspecialty Board for Critical Care Medicine. M.A. is an employee of the InfusionNurses Society, Honoraria from 3M, Becton Dickinson, Smiths Medical. L.A.B. is a consultant forInstitute of Healthcare Improvement, Board membership for Theradoc, Medline. Honorariafrom APIC, Clorox. E.P.D. consulting from Merck, Baxter, Ortho-McNeil, Targanta, ScheringPlough, Optimer, Cadence, Cardinal, BDGeneOhm, WebEx, Cerebrio, and Tyco. Grant supportthrough the NIH. Payment for lecture from Merck. Payment for development of educationalpresentation from Medscape. Travel and meeting expenses paid for by ASHP, IDSA, ASM,American College of Surgeons, NQF, SHEA/CDC, HHS, Trauma Shock Inflammation and SepsisMeeting (Munich), University of Minnesota. J.G. Honoria from Ethicon. S.O.H. provides researchsupport from Angiotech; Honoraria from Angiotech, Merck. L.A.M provides research supportfrom Astellas, Theravance, Pfizer; Consulting for Ash Access, Cadence, CorMedix, CatheterConnections, Carefusion, Sage, Bard, Teleflex; Payment for manuscript preparation fromCatheter Connections. I.I.R. provides research support from Cubist, Enzon, and Basilea;Consulting for Clorox; Stock Equity or Options in Great Lakes Pharmaceuticalsand InventiveProtocol; Speakers Bureau for Cook, Inc.; Royalty income (patents owned by MD Anderson onwhich Dr. Raad in an inventor: American Medical Systems, Cook, Inc., Cook urological, Teleflex,TyRx, Medtronic, Biomet, Great Lakes Pharmaceuticals. A.R. consulting income from EisaiPharmaceuticals, Discovery Laboratories. M.E.R. provides research support from Molnlycke,Cardinal Healthcare Foundation, Sanofi-Pasteur, 3M, and Cubist; Consulting from Semprus;Honorarium for lectures from 3M, Carefusion, Baxter and Becton Dickinson. Previously servedon Board of Directors for Society for Healthcare Epidemiology of America. All other authors: noconflicts.Last update: October 2017Page 4 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)Table of ContentsNotice to Readers: . 7Introduction . 8Summary of Recommendations . 81. Education, Training and Staffing . 84. Maximal Sterile Barrier Precautions. 115. Skin Preparation . 116. Catheter Site Dressing Regimens . 127. Patient Cleansing . 148. Catheter Securement Devices . 149. Antimicrobial/Antiseptic Impregnated Catheters and Cuffs. 1410. Systemic Antibiotic Prophylaxis . 1511. Antibiotic/Antiseptic Ointments . 1512. Antibiotic Lock Prophylaxis, Antimicrobial Catheter Flush and Catheter Lock Prophylaxis . 1513. Anticoagulants . 1514. Replacement of Peripheral and Midline Catheters. 1515. Replacement of CVCs, Including PICCs and Hemodialysis Catheters . 1616. Umbilical Catheters . 1617. Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and PediatricPatients . 1718. Replacement of Administration Sets. 1819. Needleless Intravascular Catheter Systems . 1920. Performance Improvement . 19Background Information . 19Terminology and Estimates of Risk. 19Table 1. Catheters Used for Venous and Arterial Access . 21Epidemiology and Microbiology in Adult and Pediatric Patients . 22Pathogenesis . 22Strategies for Prevention of Catheter-Related Infections in Adult and Pediatric Patients . 24Education, Training and Staffing . 24Selection of Catheters and Sites . 25Hand Hygiene and Aseptic Technique . 28Maximal Sterile Barrier Precautions . 29Skin Preparation. 30Catheter Site Dressing Regimens . 31Patient Cleansing . 35Catheter Securement Devices . 35Antimicrobial/Antiseptic Impregnated Catheters and Cuffs . 35Systemic Antibiotic Prophylaxis . 38Antibiotic/Antiseptic Ointments . 39Antibiotic Lock Prophylaxis, Antimicrobial Catheter Flush and Catheter Lock Prophylaxis . 40Anticoagulants . 42Replacement of Peripheral and Midline Catheters . 44Last update: October 2017Page 5 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)Replacement of CVCs, Including PICCs and Hemodialysis Catheters . 45Umbilical Catheters. 48Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and PediatricPatients . 50Replacement of Administration Sets . 51Needleless Intravascular Catheter Systems. 52Performance Improvement . 55Updated Recommendations References . 58References . 58Last update: October 2017Page 6 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)Notice to Readers:Content Removed [October 2017]: Content in the Notice to Readers section was removedto reflect the recommendation update and the evolution of CDC infection control guidelinemethodology.These guidelines have been developed for healthcare personnel who insert intravascularcatheters and for persons responsible for surveillance and control of infections in hospital,outpatient, and home healthcare settings. This report was prepared by a working groupcomprising members from professional organizations representing the disciplines of critical caremedicine, infectious diseases, healthcare infection control, surgery, anesthesiology, interventionalradiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by theSociety of Critical Care Medicine (SCCM), in collaboration with the Infectious Diseases Society ofAmerica (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society(SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), AmericanSociety of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Controland Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), AmericanSociety for Parenteral and Enteral Nutrition (ASPEN), Society of Interventional Radiology (SIR),American Academy of Pediatrics (AAP), Pediatric Infectious Diseases Society (PIDS), and theHealthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for DiseaseControl and Prevention (CDC) and is intended to replace the Guideline for Prevention ofIntravascular Catheter-Related Infections published in 2002.The system for categorizing Recommendations in this guideline is as follows:Category IA. Strongly recommended for implementation and strongly supported by welldesigned experimental, clinical, or epidemiologic studies.Category IB. Strongly recommended for implementation and supported by some experimental,clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g.,aseptic technique) supported by limited evidence.Category IC. Required by state or federal regulations, rules, or standards.Category II. Suggested for implementation and supported by suggestive clinical orepidemiologic studies or a theoretical rationale.Unresolved issue. Represents an unresolved issue for which evidence is insufficient or noconsensus regarding efficacy exists.Last update: October 2017Page 7 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)IntroductionIn the United States, 15 million central vascular catheter (CVC) days (i.e., the total number ofdays of exposure to CVCs among all patients in the selected population during the selected timeperiod) occur in intensive care units (ICUs) each year [1]. Studies have variously addressed catheterrelated bloodstream infections (CRBSI). These infections independently increase hospital costs andlength of stay [2-5], but have not generally been shown to independently increase mortality. While80,000 CRBSIs occur in ICUs each year [1], a total of 250,000 cases of BSIs have been estimated tooccur annually, if entire hospitals are assessed [6]. By several analyses, the cost of these infections issubstantial, both in terms of morbidity and financial resources expended. To improve patientoutcome and to reduce healthcare costs, there is considerable interest by healthcare providers,insurers, regulators, and patient advocates in reducing the incidence of these infections. This effortshould be multidisciplinary, involving healthcare professionals who order the insertion and removalof CVCs, those personnel who insert and maintain intravascular catheters, infection controlpersonnel, healthcare managers including the chief executive officer (CEO) and those who allocateresources, and patients who are capable of assisting in the care of their catheters.The goal of an effective prevention program should be the elimination of CRBSI from all patientcare areas. Although this is challenging, programs have demonstrated success, but sustainedelimination requires continued effort. The goal of the measures discussed in this document is toreduce the rate to as low as feasible given the specific patient population being served, the universalpresence of microorganisms in the human environment, and the limitations of current strategiesand technologies.Summary of RecommendationsEdit [February 2017]: An * indicates recommendations that were renumbered for clarity.The renumbering does not constitute change to the intent of the recommendations.1. * Education, Training and Staffing1. Educate healthcare personnel regarding the indications for intravascular catheter use,proper procedures for the insertion and maintenance of intravascular catheters, andappropriate infection control measures to prevent intravascular catheter-relatedinfections [7–15]. Category IA2. Periodically assess knowledge of and adherence to guidelines for all personnel involved inthe insertion and maintenance of intravascular catheters [7–15]. Category IALast update: October 2017Page 8 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)3. Designate only trained personnel who demonstrate competence for the insertion andmaintenance of peripheral and central intravascular catheters. [14–28]. Category IA4. Ensure appropriate nursing staff levels in ICUs. Observational studies suggest that ahigher proportion of "pool nurses" or an elevated patient–to-nurse ratio is associatedwith CRBSI in ICUs where nurses are managing patients with CVCs [29–31]. Category IB2.* Selection of Catheters and Sites2.1. * Peripheral Catheters and Midline Catheters1. In adults, use an upper-extremity site for catheter insertion. Replace a catheter insertedin a lower extremity site to an upper extremity site as soon as possible. Category II2. In pediatric patients, the upper or lower extremities or the scalp (in neonates or younginfants) can be used as the catheter insertion site [32, 33]. Category II3. Select catheters on the basis of the intended purpose and duration of use, knowninfectious and non-infectious complications (e.g., phlebitis and infiltration), andexperience of individual catheter operators [33–35]. Category IB4. Avoid the use of steel needles for the administration of fluids and medication that mightcause tissue necrosis if extravasation occurs [33, 34]. Category IA5. Use a midline catheter or peripherally inserted central catheter (PICC), instead of a shortperipheral catheter, when the duration of IV therapy will likely exceed six days. Category II6. Evaluate the catheter insertion site daily by palpation through the dressing to discerntenderness and by inspection if a transparent dressing is in use. Gauze and opaquedressings should not be removed if the patient has no clinical signs of infection. If thepatient has local tenderness or other signs of possible CRBSI, an opaque dressing shouldbe removed and the site inspected visually. Category II7. Remove peripheral venous catheters if the patients develops signs of phlebitis (warmth,tenderness, erythema or palpable venous cord), infection, or a malfunctioning catheter[36]. Category IB2.2. * Central Venous Catheters1. Weigh the risks and benefits of placing a central venous device at a recommended site toLast update: October 2017Page 9 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)reduce infectious complications against the risk for mechanical complications (e.g.,pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian veinstenosis, hemothorax, thrombosis, air embolism, and catheter misplacement) [37–53].Category IA2. Avoid using the femoral vein for central venous access in adult patients [38, 50, 51, 54].Category IA3. Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimizeinfection risk for nontunneled CVC placement [50–52]. Category IB4. No recommendation can be made for a preferred site of insertion to minimize infectionrisk for a tunneled CVC. Unresolved issue5. Avoid the subclavian site in hemodialysis patients and patients with advanced kidneydisease, to avoid subclavian vein stenosis [53,55–58]. Category IA6. Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanentaccess for dialysis [59]. Category IA7. Use ultrasound guidance to place central venous catheters (if this technology is available)to reduce the number of cannulation attempts and mechanical complications. Ultrasoundguidance should only be used by those fully trained in its technique. [60–64]. Category IB8. Use a CVC with the minimum number of ports or lumens essential for the management ofthe patient [65–68]. Category IB9. No recommendation can be made regarding the use of a designated lumen for parenteralnutrition. Unresolved issue10. Promptly remove any intravascular catheter that is no longer essential [69–72]. Category IA11. When adherence to aseptic technique cannot be ensured (i.e., catheters inserted during amedical emergency), replace the catheter as soon as possible, i.e., within 48 hours [37,73–76]. Category IB3.* Hand Hygiene and Aseptic Technique1. Perform hand hygiene procedures, either by washing hands with conventional soap andwater or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed beforeand after palpating catheter insertion sites as well as before and after inserting, replacing,accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion siteLast update: October 2017Page 10 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)should not be performed after the application of antiseptic, unless aseptic technique ismaintained [12, 77–79]. Category IB2. Maintain aseptic technique for the insertion and care of intravascular catheters [37, 73,74, 76]. Category IB3. Wear clean gloves, rather than sterile gloves, for the insertion of peripheral intravascularcatheters, if the access site is not touched after the application of skin antiseptics.Category IC4. Sterile gloves should be worn for the insertion of arterial, central, and midline catheters[37, 73, 74, 76]. Category IA5. Use new sterile gloves before handling the new catheter when guidewire exchanges areperformed. Category II6. Wear either clean or sterile gloves when changing the dressing on intravascular catheters.Category IC4. * Maximal Sterile Barrier Precautions1. Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown,sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewireexchange [14, 75, 76, 80]. Category IB2. Use a sterile sleeve to protect pulmonary artery catheters during insertion [81]. Category IB5. * Skin Preparation1. Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, or alcoholicchlorhexidine gluconate solution) before peripheral venous catheter insertion [82].Category IB2. Prepare clean skin with a 0.5% chlorhexidine preparation with alcohol before centralvenous catheter and peripheral arterial catheter insertion and during dressing changes. Ifthere is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70%alcohol can be used as alternatives [82, 83]. Category IA3. No comparison has been made between using chlorhexidine preparations with alcoholand povidone-iodine in alcohol to prepare clean skin. Unresolved issue.Last update: October 2017Page 11 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)4. No recommendation can be made for the safety or efficacy of chlorhexidine in infantsaged 2 months. Unresolved issue5. Antiseptics should be allowed to dry according to the manufacturer’s recommendationprior to placing the catheter [82, 83]. Category IB6. * Catheter Site Dressing Regimens1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover thecatheter site [84–87]. Category IA2. If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing untilthis is resolved [84–87]. Category II3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled[84, 85]. Category IB4. Do not use topical antibiotic ointment or creams on insertion sites, except for dialysiscatheters, because of their potential to promote fungal infections and antimicrobialresistance [88, 89]. Category IB5. Do not submerge the catheter or catheter site in water. Showering should be permittedif precautions can be taken to reduce the likelihood of introducing organisms into thecatheter (e.g., if the catheter and connecting device are protected with an impermeablecover during the shower) [90–92]. Category IB6. Replace dressings used on short-term CVC sites every 2 days for gauze dressings. CategoryII7. Replace dressings used on short-term CVC sites at least every 7 days for transparentdressings, except in those pediatric patients in which the risk for dislodging the cathetermay outweigh the benefit of changing the dressing [87, 93]. Category IB8. Replace transparent dressings used on tunneled or implanted CVC sites no more thanonce per week (unless the dressing is soiled or loose), until the insertion site has healed.Category II9. No recommendation can be made regarding the necessity for any dressing on well-healed exit sites of long-term cuffed and tunneled CVCs. Unresolved issue10. Ensure that catheter site care is compatible with the catheter material [94, 95].Category IBLast update: October 2017Page 12 of 80

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011)11. Use a sterile sleeve for all pulmonary artery catheters [81]. Category IB12.Recommendation Update [July 2017] Forpatients aged 18 years and older:a. Chlorhexidine-impregnated dressings with anFDA-cleared label that specifies a clinicalindication for reducing catheter-relatedbloodstream infection (CRBSI) or catheterassociated blood stream infection (CABSI) arerecommended to protect the insertion site ofshort-term, non-tunneled central venousSupersededRecommendationsRecommendations 12 & 13have been superseded. Seethe UpdatedRecommendations s/index.html) formore information.catheters. Updated Recommendations References 8-12 Category IA(See Updated Chlorhexidine-Impregnated Dressings, ImplementationConsiderati

Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011) Last update: October 2017 Page 5 of 80 Table of Contents Notice to Readers: .

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