To the Editor—We read with interest the recent article “CLABSI or Munchausen’s or Both”Reference Kenneth, Zangwill, Marin and Vu ¹ because, among other aspects, it addressed the interactions between patient psychosocial status and general medical quality and safety measures. This is an important consideration. After all, from the ideals of the patient safety/quality improvement movement, safety is “everyone’s responsibility” and the patient is a member of the team. The inability of the patient to ally with the team’s goals diminishes teamwork and, thereby, increases the risk of errors or adverse outcomes.

However, we were disappointed with the dichotomy posed by the authors. In their analysis, the infection in the patient’s bloodstream was a manifestation of a psychiatric disorder and necessarily not a CLABSI. The article’s title entertained the possibility that the situation represented both Munchausen’s (actually named Factitious Disorder) as well as a CLABSI, but the authors determined that the patient-induced infection indicated that the infection was not a CLABSI. We disagree with this analysis for two reasons.

First, based on the information provided, the patient’s condition affirmatively appears to be a CLABSI. There is no reason not to classify this bloodstream infection as a CLABSI. Even though the patient’s symptoms could have possibly been caused by manipulation, it still counts as a CLABSI per the NHSN surveillance definitions based on the information provided. In the Centers for Disease Control and Prevention (CDC) Device-Associated Module (both the January 2014 and January 2015 releases ² ), it is noted that “Patients suspected or known to have accessed their own IV lines are not excluded from CLABSI surveillance. A facility must protect the line as best they can. Prevention efforts may include providing a patient sitter and/or removal of the catheter as soon as is clinically possible.” Every organization is responsible to report these infections to the best of their ability based on the surveillance definitions. Not doing so skews the data collected and reported to the Centers for Medicare and Medicaid Services (CMS).

From another perspective, there is no reason to exclude the infection simply because it was self-induced as a part of a psychiatric disorder. Instead, we would suggest that the individual whose body has a central line is a person vulnerable to a blood stream infection and that individuals with some psychiatric disorders may have a heightened degree of risk. There are several potential pathways toward CLABSI, and the presence of a psychiatric disorder should be considered as a potential mechanism by which an infection may occur either intentionally (as in this case) or unintentionally. Rather than excluding psychiatric conditions from CLABSI prevention, we propose increased attention to the interplay between psychiatric conditions and CLABSIs in individual cases as well as systematically, and such an analysis is now underway at our institution.