The New England journal of medicine
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In a one month period, 10 Serratia liquefaciens bloodstream infections and 6 pyrogenic reactions occurred in outpatients at a hemodialysis center. ⋯ Puncturing single-use vials multiple times and pooling preservative-free epoetin alfa caused this outbreak of bloodstream infections in a hemodialysis unit. To prevent similar outbreaks, medical personnel should follow the manufacturer's guidelines for the use of preservative-free medications.