Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee

НазваниеJane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee
Размер1.04 Mb.
1   ...   7   8   9   10   11   12   13   14   ...   24
Part IV:


These recommendations are designed to prevent transmission of infectious agents among patients and healthcare personnel in all settings where healthcare is delivered. As in other CDC/HICPAC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and when possible, economic impact. The CDC/HICPAC system for categorizing recommendations is as follows: Category IA Strongly recommended for implementation and strongly supported by well-designed 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. Category IC Required for implementation, as mandated by federal and/or state regulation or standard. Category II Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. No recommendation; unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

I. Administrative Responsibilities

Healthcare organization administrators should ensure the implementation of recommendations in this section.

I.A. Incorporate preventing transmission of infectious agents into the objectives of the organization’s patient and occupational safety programs

543-546, 561, 620, 626, 946. Category IB/IC

I.B. Make preventing transmission of infectious agents a priority for the healthcare organization. Provide administrative support, including fiscal and human resources for maintaining infection control programs 434, 548, 549,

559, 561, 566, 662 552, 562-564, 946. Category IB/IC

I.B.1. Assure that individuals with training in infection control are employed by or are available by contract to all healthcare facilities so that the infection control program is managed by one or more qualified individuals 552, 566 316, 575, 947 573, 576, 946. Category IB/IC

I.B.1.a. Determine the specific infection control full-time equivalents (FTEs) according to the scope of the infection control program, the complexity of the healthcare facility or system, the characteristics of the patient population, the unique or urgent needs of the facility and community, and proposed staffing levels based on survey results and recommendations from

professional organizations 434, 549 552, 566 316, 569, 573, 575 948 949


Category IB

I.B.2. Include prevention of healthcare-associated infections (HAI) as one determinant of bedside nurse staffing levels and composition,

especially in high-risk units 585-589 590 592 593 551, 594, 595 418, 596, 597 583


Category IB

I.B.3. Delegate authority to infection control personnel or their designees (e.g., patient care unit charge nurses) for making infection control decisions concerning patient placement and assignment of Transmission-Based Precautions 549 434, 857, 946. Category IC

I.B.4. Involve infection control personnel in decisions on facility construction and design, determination of AIIR and Protective Environment capacity needs and environmental assessments 11, 13,

950 951 12

. Category IB/IC

I.B.4.a. Provide ventilation systems required for a sufficient number of AIIRs (as determined by a risk assessment) and Protective Environments in healthcare facilities that provide care to patients for whom such rooms are indicated, according to published recommendations 11-13, 15. Category IB/IC

I.B.5. Involve infection control personnel in the selection and post-implementation evaluation of medical equipment and supplies and changes in practice that could affect the risk of HAI 952, 953. Category IC

I.B.6. Ensure availability of human and fiscal resources to provide clinical microbiology laboratory support, including a sufficient number of medical technologists trained in microbiology, appropriate to the healthcare setting, for monitoring transmission of microorganisms, planning and conducting epidemiologic investigations, and detecting emerging pathogens. Identify resources for performing surveillance cultures, rapid diagnostic testing for viral and other selected pathogens, preparation of antimicrobial susceptibility summary reports, trend analysis, and molecular typing of clustered isolates (performed either on-site or in a reference laboratory) and use these resources according to facility-specific epidemiologic needs, in consultation with clinical microbiologists 553, 609, 610, 612, 617,

954 614 603, 615, 616 605 599 554 598, 606, 607. Category IB

I.B.7. Provide human and fiscal resources to meet occupational health needs related to infection control (e.g., healthcare personnel immunization, post-exposure evaluation and care, evaluation and management of healthcare personnel with communicable infections

739 12 17, 879-881, 955 134 690. Category IB/IC

I.B.8. In all areas where healthcare is delivered, provide supplies and equipment necessary for the consistent observance of Standard Precautions, including hand hygiene products and personal protective equipment (e.g., gloves, gowns, face and eye protection)

739 559 946

. Category IB/IC

I.B.9. Develop and implement policies and procedures to ensure that reusable patient care equipment is cleaned and reprocessed appropriately before use on another patient 11, 956 957, 958 959 836 87 11,

960 961

. Category IA/IC

I.C. Develop and implement processes to ensure oversight of infection control activities appropriate to the healthcare setting and assign responsibility for oversight of infection control activities to an individual or group within the healthcare organization that is knowledgeable about infection control 434, 549, 566. Category II

I.D. Develop and implement systems for early detection and management (e.g., use of appropriate infection control measures, including isolation precautions, PPE) of potentially infectious persons at initial points of patient encounter in outpatient settings (e.g., triage areas, emergency departments, outpatient clinics, physician offices) and at the time of admission to hospitals and long-term care facilities (LTCF) 9, 122, 134, 253, 827.

Category IB

I.E. Develop and implement policies and procedures to limit patient visitation by persons with signs or symptoms of a communicable infection. Screen visitors to high-risk patient care areas (e.g., oncology units, hematopoietic stem call transplant [HSCT] units, intensive care units, other severely immunocompromised patients) for possible infection 43 24, 41, 962,


.Category IB

I.F. Identify performance indicators of the effectiveness of organization-specific measures to prevent transmission of infectious agents (Standard and Transmission-Based Precautions), establish processes to monitor adherence to those performance measures and provide feedback to staff

members 704 739 705 708 666, 964 667 668 555. Category IB

II. Education and Training

II.A. Provide job- or task-specific education and training on preventing transmission of infectious agents associated with healthcare during orientation to the healthcare facility; update information periodically during ongoing education programs. Target all healthcare personnel for education and training, including but not limited to medical, nursing, clinical technicians, laboratory staff; property service (housekeeping), laundry, maintenance and dietary workers; students, contract staff and volunteers. Document competency initially and repeatedly, as appropriate, for the specific staff positions. Develop a system to ensure that healthcare personnel employed by outside agencies meet these education and training requirements through programs offered by the agencies or by participation in the healthcare facility’s program designed for full-time

personnel 126, 559, 561, 562, 655, 681-684, 686, 688, 689, 702, 893, 919, 965. Category IB

II.A.1. Include in education and training programs, information concerning use of vaccines as an adjunctive infection control measure 17, 611, 690, 874. Category IB

II.A.2. Enhance education and training by applying principles of adult learning, using reading level and language appropriate material for the target audience, and using online educational tools available to

the institution 658, 694, 695, 697, 698, 700, 966. Category IB


II.B. Provide instructional materials for patients and visitors on recommended hand hygiene and Respiratory Hygiene/Cough Etiquette practices and the application of Transmission-Based Precautions 9, 709, 710, 963. Category II


III.A. Monitor the incidence of epidemiologically-important organisms and targeted HAIs that have substantial impact on outcome and for which effective preventive interventions are available; use information collected through surveillance of high-risk populations, procedures, devices and highly transmissible infectious agents to detect transmission of infectious

agents in the healthcare facility 566, 671, 672, 675, 687, 919, 967, 968 673 969 970


Category IA

III.B. Apply the following epidemiologic principles of infection surveillance 671, 967

673 969 663 664

. Category IB y Use standardized definitions of infection y Use laboratory-based data (when available) y Collect epidemiologically-important variables (e.g., patient locations

and/or clinical service in hospitals and other large multi-unit facilities, population-specific risk factors [e.g., low birth-weight neonates], underlying conditions that predispose to serious adverse outcomes)

y Analyze data to identify trends that may indicated increased rates of transmission

y Feedback information on trends in the incidence and prevalence of HAIs, probable risk factors, and prevention strategies and their impact to the appropriate healthcare providers, organization administrators, and as required by local and state health authorities

III.C. Develop and implement strategies to reduce risks for transmission and evaluate effectiveness 566, 673, 684, 970 963 971. Category IB

III.D. When transmission of epidemiologically-important organisms continues despite implementation and documented adherence to infection prevention and control strategies, obtain consultation from persons knowledgeable in infection control and healthcare epidemiology to review the situation and recommend additional measures for control 566 247 687 . Category IB

III.E. Review periodically information on community or regional trends in the incidence and prevalence of epidemiologically-important organisms (e.g., influenza, RSV, pertussis, invasive group A streptococcal disease, MRSA, VRE) (including in other healthcare facilities) that may impact transmission of organisms within the facility 398, 687, 972, 973 974. Category II

IV. Standard Precautions Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care.

IV.A. Hand Hygiene

IV.A.1. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces72,

73 739, 800, 975{CDC, 2001 #970. Category IB/IC

IV.A.2. When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water 559. Category IA

IV.A.3. If hands are not visibly soiled, or after removing visible material with nonantimicrobial soap and water, decontaminate hands in the clinical situations described in IV.A.2.a-f. The preferred method of hand decontamination is with an alcohol-based hand rub 562, 978. Alternatively, hands may be washed with an antimicrobial soap and water. Frequent use of alcohol-based hand rub immediately following handwashing with nonantimicrobial soap may increase the frequency of dermatitis 559. Category IB Perform hand hygiene:

IV.A.3.a. Before having direct contact with patients 664, 979. Category IB

IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings 664. Category IA

IV.A.3.c. After contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure or lifting a patient) 167, 976, 979, 980.

Category IB

IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care. Category II

IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient 72, 73, 88, 800, 981


. Category II

IV.A.3.f. After removing gloves 728, 741, 742. Category IB

IV.A.4. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores 559, 956, 983.

Category II

IV.A.5. Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes (e.g., those in ICUs or operating rooms) 30, 31, 559,


. Category IA

IV.A.5.a. Develop an organizational policy on the wearing of non-natural nails by healthcare personnel who have direct contact with patients outside of the groups specified above 984. Category II

IV.B. Personal protective equipment (PPE) (see Figure)

IV.B.1. Observe the following principles of use:

IV.B.1.a. Wear PPE, as described in IV.B.2-4,when the nature of the anticipated patient interaction indicates that contact with blood or body fluids may occur 739, 780, 896. Category IB/IC

IV.B.1.b. Prevent contamination of clothing and skin during the process of removing PPE (see Figure). Category II

IV.B.1.c. Before leaving the patient’s room or cubicle, remove and discard PPE 18, 739. Category IB/IC



IV.B.2.a. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur

18, 728, 739, 741, 780, 985. Category IB/IC

IV.B.2.b. Wear gloves with fit and durability appropriate to the task 559, 731,

732, 739, 986, 987. Category IB

IV.B.2.b.i. Wear disposable medical examination gloves for providing direct patient care.

. Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical equipment.

IV.B.2.c. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination (see Figure). Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens 559, 728, 741-743, 988. Category IB

IV.B.2.d. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face). Category II



IV.B.3.a. Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated 739, 780, 896. Category IB/IC

IV.B.3.a.i. Wear a gown for direct patient contact if the patient has uncontained secretions or excretions 24, 88, 89, 739, 744

Category IB/IC

. Remove gown and perform hand hygiene before leaving the patient’s environment 24, 88, 89, 739, 744 Category IB/IC

IV.B.3.b. Do not reuse gowns, even for repeated contacts with the same patient. Category II

IV.B.3.c. Routine donning of gowns upon entrance into a high risk unit (e.g., ICU, NICU, HSCT unit) is not indicated 365, 747-750. Category IB

IV.B.4. Mouth, nose, eye protection

IV.B.4.a. Use PPE to protect the mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed 113, 739, 780, 896. Category IB/IC

IV.B.5. During aerosol-generating procedures (e.g., bronchoscopy, suctioning of the respiratory tract [if not using in-line suction catheters], endotracheal intubation) in patients who are not suspected of being infected with an agent for which respiratory protection is otherwise recommended (e.g., M. tuberculosis, SARS or hemorrhagic fever viruses), wear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and

gown) 95, 96, 113, 126 93 94, 134. Category IB

IV.C. Respiratory Hygiene/Cough Etiquette

IV.C.1. Educate healthcare personnel on the importance of source control measures to contain respiratory secretions to prevent droplet and fomite transmission of respiratory pathogens, especially during seasonal outbreaks of viral respiratory tract infections (e.g., influenza, RSV, adenovirus, parainfluenza virus) in communities 14,

24, 684 10, 262. Category IB


Implement the following measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at the point of initial encounter in a healthcare setting (e.g., triage, reception and waiting areas in emergency departments, outpatient clinics and physician

offices) 20, 24, 145, 902, 989


IV.C.2.a. Post signs at entrances and in strategic places (e.g., elevators, cafeterias) within ambulatory and inpatient settings with instructions to patients and other persons with symptoms of a respiratory infection to cover their mouths/noses when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands have been in contact with respiratory secretions. Category II

IV.C.2.b. Provide tissues and no-touch receptacles (e.g.,foot-pedal­operated lid or open, plastic-lined waste basket) for disposal of tissues 20. Category II

IV.C.2.c. Provide resources and instructions for performing hand hygiene in or near waiting areas in ambulatory and inpatient settings; provide conveniently-located dispensers of alcohol-based hand rubs and, where sinks are available, supplies for handwashing

559, 903. Category IB

IV.C.2.d. During periods of increased prevalence of respiratory infections in the community (e.g., as indicated by increased school absenteeism, increased number of patients seeking care for a respiratory infection), offer masks to coughing patients and other symptomatic persons (e.g., persons who accompany ill patients) upon entry into the facility or medical office 126, 899 898 and encourage them to maintain special separation, ideally a distance of at least 3 feet, from others in common waiting areas

23, 103, 111, 114 20, 134. Category IB

IV.C.2.d.i. Some facilities may find it logistically easier to institute this recommendation year-round as a standard of practice. Category II

IV.D. Patient placement

IV.D.1. Include the potential for transmission of infectious agents in patient-placement decisions. Place patients who pose a risk for transmission to others (e.g., uncontained secretions, excretions or wound drainage; infants with suspected viral respiratory or gastrointestinal infections) in a single-patient room when available

24, 430, 435, 796, 797, 806, 990 410, 793. Category IB

IV.D.2. Determine patient placement based on the following principles: y Route(s) of transmission of the known or suspected infectious

agent y Risk factors for transmission in the infected patient y Risk factors for adverse outcomes resulting from an HAI in other

patients in the area or room being considered for patient-

placement y Availability of single-patient rooms y Patient options for room-sharing (e.g., cohorting patients with

the same infection) Category II

IV.E. Patient-care equipment and instruments/devices 956

IV.E.1. Establish policies and procedures for containing, transporting, and handling patient-care equipment and instruments/devices that may be contaminated with blood or body fluids 18, 739, 975. Category IB/IC

IV.E.2. Remove organic material from critical and semi-critical instrument/devices, using recommended cleaning agents before high level disinfection and sterilization to enable effective disinfection and sterilization processes 836 991, 992. Category IA

IV.E.3. Wear PPE (e.g., gloves, gown), according to the level of anticipated contamination, when handling patient-care equipment and instruments/devices that is visibly soiled or may have been in contact with blood or body fluids 18, 739, 975. Category IB/IC

IV.F. Care of the environment 11

IV.F.1. Establish policies and procedures for routine and targeted cleaning of environmental surfaces as indicated by the level of patient contact and degree of soiling 11. Category II

IV.F.2. Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient (e.g., bed rails, over bed tables) and frequently-touched surfaces in the patient care environment (e.g., door knobs, surfaces in and surrounding toilets in patients’ rooms) on a more frequent schedule compared to that for other surfaces (e.g., horizontal surfaces in

waiting rooms) 11 73, 740, 746, 993, 994 72, 800, 835 995. Category IB

IV.F.3. Use EPA-registered disinfectants that have microbiocidal (i.e., killing) activity against the pathogens most likely to contaminate the patient-care environment. Use in accordance with manufacturer’s instructions 842-844, 956, 996. Category IB/IC

IV.F.3.a. Review the efficacy of in-use disinfectants when evidence of continuing transmission of an infectious agent (e.g., rotavirus, C. difficile, norovirus) may indicate resistance to the in-use product and change to a more effective disinfectant as indicated 275, 842,


. Category II

IV.F.4. In facilities that provide health care to pediatric patients or have waiting areas with child play toys (e.g., obstetric/gynecology offices and clinics), establish policies and procedures for cleaning and disinfecting toys at regular intervals 379 80 . Category IB

• Use the following principles in developing this policy and procedures: Category II y Select play toys that can be easily cleaned and disinfected y Do not permit use of stuffed furry toys if they will be shared y Clean and disinfect large stationary toys (e.g., climbing

equipment) at least weekly and whenever visibly soiled y If toys are likely to be mouthed, rinse with water after disinfection; alternatively wash in a dishwasher

y When a toy requires cleaning and disinfection, do so immediately or store in a designated labeled container separate from toys that are clean and ready for use

IV.F.5. Include multi-use electronic equipment in policies and procedures for preventing contamination and for cleaning and disinfection, especially those items that are used by patients, those used during delivery of patient care, and mobile devices that are moved in and out of patient rooms frequently (e.g., daily) 850 851, 852, 997. Category IB

IV.F.5.a. No recommendation for use of removable protective covers or washable keyboards. Unresolved issue

IV.G. Textiles and laundry

IV.G.1. Handle used textiles and fabrics with minimum agitation to avoid contamination of air, surfaces and persons 739, 998, 999. Category IB/IC

IV.G.2. If laundry chutes are used, ensure that they are properly designed, maintained, and used in a manner to minimize dispersion of aerosols from contaminated laundry 11, 13, 1000, 1001. Category IB/IC

IV.H. Safe injection practices The following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable intravenous delivery systems 454

IV.H.1. Use aseptic technique to avoid contamination of sterile injection equipment 1002, 1003. Category IA

IV.H.2. Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient 453, 919, 1004, 1005.

Category IA

IV.H.3. Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set 453.

Category IB

IV.H.4. Use single-dose vials for parenteral medications whenever possible


. Category IA

IV.H.5. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use 369 453,


. Category IA

IV.H.6. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile 453, 1002.

Category IA

IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer’s recommendations; discard if sterility is compromised or questionable 453, 1003. Category IA

IV.H.8. Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients 453, 1006. Category IB

IV.I. Infection control practices for special lumbar puncture procedures Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia 906 907-909 910, 911 912-914, 918 1007. Category IB


Worker safety Adhere to federal and state requirements for protection of healthcare personnel from exposure to bloodborne pathogens 739. Category IC
1   ...   7   8   9   10   11   12   13   14   ...   24


Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee iconAdvisory committee on immunization practices

Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee iconRanch hand advisory committee

Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee iconVeterinary medicine advisory committee

Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee iconMedical Devices Advisory Committee

Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee iconExternal Advisory Committee on Cities and Communities

Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee iconNational Vaccine Advisory Committee (nvac)

Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee iconWildlife Diversity Policy Advisory Committee

Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee iconStudies on dietary supplements for the control of Aeromonas hydrophila infection in rainbow trout (Oncorhynchus mykiss, Walbaum)

Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee iconPeer reviewed by the Arizona Department of Commerce Economic Research Advisory Committee

Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee iconFood and drug administration national institutes of health advisory Committee on: transmissible spongiform

Разместите кнопку на своём сайте:

База данных защищена авторским правом ©lib.znate.ru 2014
обратиться к администрации
Главная страница