Discussion

Among healthcare-associated infections, CLABSI has the greatest potential negative impact on patient outcomes, including increased mortality risk and prolonged length of hospital stay. ^{Reference Srinivas, Rivard and Pallotta1–Reference Ziegler, Pellegrini and Safdar3} CLABSI rates are also linked to hospital reimbursement through the Medicare hospital-acquired conditions reduction program and the State of Maryland’s Quality-Based Reimbursement. For these reasons, CLABSI has been declared a “never event,” and significant efforts have been undertaken to prevent its occurrence. ^{Reference Patel, Gupta and Vaughn4}

Most US states legally require public reporting of healthcare-associated infections via the National Healthcare Safety Network (NHSN). ^{Reference Herzig, Reagan and Pogorzelska-Maziarz5} According to NHSN definitions, any bloodstream infection that develops in the context of a central line and cannot be attributed to an alternative source is counted as a CLABSI. If the blood culture is positive for a qualifying pathogen, signs or symptoms of infection are not required. Determination of an alternative source of infection depends on the quality of documentation and can be subjective, introducing variability based on who does the chart review. ^{Reference Sexton, Chen and Moehring6–Reference Mayer, Greene and Howell8}

On average, the rate of CLABSI in the United States is 1.7 events per 1,000 central-line days. ^{Reference Rock, Thom and Harris9} Based on 17 CLABSIs over a single 2,000-day period, this patient’s individual CLABSI rate was 8.5 events per 1,000 central-line days. These CLABSIs accounted for 27% of all CLABSIs occurring at his admitting hospital. During this period, the NHSN-defined CLABSI rate reflected the largely unmodifiable circumstances of a single patient instead of the quality of care received by most patients at this hospital.

CLABSI prevention is difficult and requires engagement by the entire healthcare team. Efforts to maintain that engagement can be undermined when publicly reported rates are biased to suggest that infection prevention practices do not make a difference. When staff are less motivated, the expectation of recurrent CLABSI can become self-fulfilling. These unintended consequences of public reporting are likely most relevant when options for out-of-hospital care are limited, as is often true for socioeconomically disadvantaged patients.

Although CLABSI is a considered a “never event,” CLABSIs may be inevitable for some patients. For this patient, multiple CLABSIs occurred despite attentive delivery of evidence-based preventive measures. Although this case is an extreme example, recurrent infections are not uncommon in our experience. We have observed similar occurrences for other NHSN-defined infections, including catheter-associated urinary tract infection, Clostridioides difficile infection, and methicillin-resistant Staphylococcus aureus bacteremia.

We suggest that recurrent NHSN-defined infection of the same type in a single patient is more likely to be a consequence of the unmodifiable susceptibility of the patient than the quality of care delivered. To reduce bias, NHSN should consider revising the definition of CLABSI and other healthcare-associated infections to exclude patients who have already developed the same infection during the same hospitalization, regardless of the time elapsed between episodes.