Understand the challenges to overcome them.

DESPITE EXTENSIVE RESEARCH and updates to practice guidelines, urinary tract infections (UTIs) remain a common occurrence within long-term care (LTC) facilities. The Centers for Disease Control and Prevention (CDC) reports that 20% of UTIs occur in these facilities. For most healthy adults, a full dose of antibiotics leads to complete recovery, but failure to recognize UTI symptoms and respond promptly can lead to more ominous outcomes, including urosepsis.

The National Academies of Sciences, Engineering, and Medicine (National Academies) acknowledges the complexities of treating older adults who live in LTC facilities. Stark differences in diagnostic capabilities exist between LTC facilities and acute-care hospitals, including limited access to medical supplies, communication challenges with providers, lack of testing availability, and inadequate staff training. Identifying and addressing these barriers can help prevent the development of urosepsis secondary to UTI and ensure positive patient outcomes.

Urosepsis in LTC facilities

According to the CDC, every year, approximately 1.7 million Americans are diagnosed with sepsis. Guliciuc and colleagues note that urosepsis accounts for up to 31% of sepsis cases, and Tocut and colleagues report that advanced age (>65 years) and comorbidities result in higher urosepsis mortality rates.

The challenge of preventing UTI within LTC facilities remains complex. Healthcare-acquired UTI surveillance data published by the CDC estimates that 20% of infections acquired within LTC facilities are UTIs. Untreated, these infections may develop into urosepsis, a systemic infection with a high mortality rate among older adults. Current practices to prevent UTI include hydration, supplementation with cranberry extract and vitamin C, proper hygiene, and avoiding unnecessary urinary catheterization.

A study published by the National Kidney Foundation confirmed that urinalysis with culture and sensitivity remains the gold standard for diagnosing UTI; blood specimens may be ordered to rule out urosepsis. According to Porat and colleagues, ultrasonography is more than 90% effective in diagnosing renal obstructions that commonly cause UTI. Its noninvasive nature makes it a viable option for older patients. The standard treatment for UTI includes antibiotics, fluids, and symptom management.

Barriers to detection

Hsiao and colleagues report that several factors place older adults at risk for contracting a UTI, including age-related changes (such as self-care deficits, altered sensory perception, cognition changes) and staffing, facility, and provider limitations.

Age-related changes

Age-related changes influence how symptoms of infection manifest in older adults, making early recognition challenging. Traditionally, fever and leukocytosis serve as reliable indicators of infection for those with healthy immune systems, but many older adults experience a diminished immune response. Dutta and colleagues reported that older adults with infections may remain afebrile and demonstrate absent or delayed leukocytosis.

Some patients may not report symptoms as a result of age-related sensory deficits that affect their ability to recognize and report abnormal symptoms. Delirium frequently accompanies infection in older adults. According to Dutta and colleagues, caregivers may overlook this acute change in mentation or perceive it as dementia or cognitive decline. However, a change in mental status typically arises before abnormal laboratory findings in older adults experiencing infection.

Staffing limitations

Prompt recognition of UTI begins with the nurse, but challenges specific to the LTC facility can make early recognition difficult. Many nurses working in these facilities care for as many as 30 patients. This is a staggering ratio when compared to an average of five to seven patients per nurse on a medical–surgical unit. Lasater and colleagues determined that low nurse-patient ratios result in reduced patient mortality rates. Their study found that high nurse-patient ratios lead to more adverse events caused by lack of bedside surveillance. The workload of LTC nurses reduces the amount of time spent with patients, which is critical for recognizing signs of infection.

Urosepsis requires a trained eye for early detection, which means that staff education and training of staff also have implications. Traditionally, LTC facilities don’t require certification for unlicensed assistive personnel caring for older adults. This gap in education also applies to the nursing staff. Although many hospitals require nurses to obtain a bachelor’s degree, the National Academies found that about 88% of nurses working in LTC facilities are licensed practical nurses, although evidence shows that employing baccalaureate-prepared nurses results in better patient outcomes.

Provider limitations

Most LTC facilities have limited access to providers. Physicians and nurse practitioners don’t remain on-site around the clock. Computerized provider order entry, available in most acute-care settings, reduces medication errors and the time between prescribing and treatment. However, current practice in many LTC facilities still includes faxing or calling in orders and weekly scheduled provider visits to the facility.

Facility limitations

Limited resources contribute to delays in UTI diagnosis and treatment. Preventing UTIs from developing into urosepsis requires surveillance and risk assessment, but the systems in place at LTC facilities and acute hospital settings vary. In a hospital setting, risk assessment is an interdisciplinary process. In contrast, many LTC facilities employ a risk assessment nurse who may double as the infection control nurse. The National Academies attributes failed recognition and treatment delays in LTC facilities to this lack of patient surveillance.

Immediate access to diagnostic tools assists in preventing delayed treatment and influences patient outcomes. Most hospitals have on-site laboratories for quick processing of specimens. However, many LTC facilities must store urine on-site and wait for a contracted laboratory to pick up and process the specimen. Improper handling or compromise of urine samples during the chain of custody renders them unusable, which requires new samples.

Collection of blood specimens also presents a challenge in LTC facilities without readily available supplies such as aerobic and anaerobic blood culture vials. In addition, physiological changes in an older adult and chronic dehydration can lead to difficulty obtaining blood samples. In a hospital setting, the nurse can enlist the help of emergency department staff or other vascular specialists and equipment. In the LTC setting, this task is commonly outsourced to a contracted laboratory, which sends a technician to the facility, delaying diagnosis and treatment.

LTC facilities also face challenges caring for patients with acute conditions. In an acute-care setting, the patient with urosepsis may be transferred to the intensive care unit or the rapid response team may intervene. Patients who reside in an LTC facility and have a sudden need for critical care require transfer to a hospital via ambulance. This means waiting for emergency medical services to arrive. Less critical patients may be treated at the LTC facility but remain at risk due to a lack of readily available diagnostic tools, treatment options, and providers.

Overcoming challenges

Fundamental nursing assessments (such as monitoring for mental status changes, evaluating functional decline, and determining urinary patterns) play a vital role in the early recognition of UTIs, which can lead to the prevention of urosepsis. These routine assessments allow nurses to identify atypical and subtle signs of infection in older adults, such as confusion and decreased functional ability. Care teams can improve the recognition of these signs with the use of standardized screening tools. According to Khan and colleagues, the Confusion Assessment Method and routine monitoring of residents’ baseline cognition result in more accurate detection of delirium associated with infection in this population. The tool, available through the Network for Investigational Delirium, analyzes factors such as level of consciousness and attention. LTC facilities can integrate these screening tools into their electronic health records to ensure easy accessibility by nurses.

The nurse’s role remains essential in adopting screening tools for early detection of UTI and subsequent prevention of urosepsis. Nurses should obtain a baseline cognitive evaluation upon admission and at regular intervals for prompt recognition of deviations from this baseline. They should remain responsive to family concerns about changes in cognition and incorporate this feedback into clinical assessment. According to Delgado and colleagues, families frequently notice cognitive changes before medical staff.

Therefore, effective communication between the nurse and family aids in more timely identification of infection-related delirium. By educating staff and families on the symptoms of UTIs, nurses can foster earlier recognition of signs such as altered mentation. (See Collaborative interventions.)

Prompt recognition and response

LTC facilities encounter many challenges when it comes to managing and preventing urosepsis, but prompt recognition and response can make the difference between life and death for some patients. Prevention may prove difficult given the circumstances and patient population, but early detection can reduce high-acuity cases and rates of mortality. The feasibility of preventing the progression of a UTI to urosepsis improves with staff education and the use of standardized screening tools.

Talitha Smith is a professor at Herzing University in Akron, Ohio.

American Nurse Journal. 2025; 20(11). Doi: 10.51256/ANJ112524

References

Al Lawati H, Blair BM, Larnard J. Urinary tract infections: Core curriculum 2024. Am J Kidney Dis. 2024;83(1):90-100. doi:10.1053/j.ajkd.2023.08.009

Capstick A, Palermo F, Zakka K, et al. Digital remote monitoring for screening and early detection of urinary tract infections. NPJ Digit Med. 2024;7(1):11. doi:10.1038/s41746-023-00995-5

Centers for Disease Control and Prevention. About sepsis. August 19, 2025. cdc.gov/sepsis/about/index.html

Delgado KF, Roberson D, Haberstroh A, Wei H. Nursing staff’s role in detecting urinary tract infections in nursing homes: An integrative review. J Gerontol Nurs. 2022;48(5):43-50. doi:10.3928/00989134-20220405-03

Dutta C, Pasha K, Paul S, et al. Urinary tract infection induced delirium in elderly patients: a systematic review. Cureus. 2022;14(12):e32321. doi:10.7759/cureus.32321

Guliciuc M, Maier AC, Maier IM, et al. The urosepsis—A literature review. Medicina. 2021;57(9):872. doi:10.3390/medicina57090872

Hsiao CY, Chen TH, Lee YC, Hsiao MC, Hung PH, Wang MC. Risk factors for uroseptic shock in hospitalized patients aged over 80 years with urinary tract infection. Ann Transl Med. 2020;8(7):477. doi:10.21037/atm.2020.03.95

Khan A, Heslin K, Simpson M, Malone ML. Can variables from the electronic health record identify delirium at bedside? J Patient Cent Res Rev. 2022;9(3):174-80. doi:10.17294/2330-0698.1890

Lasater KB, Aiken LH, Sloane D, et al. Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: An observational study. BMJ Open. 2021;11(12):e052899. doi:10.1136/bmjopen-2021-052899

National Academies of Sciences, Engineering, and Medicine. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: National Academies Press; 2022. doi:10.17226/26526

National Health Care Safety Network. Healthcare-associated Infection surveillance protocol for urinary tract infection (UTI) events for long-term care facilities. NHSN. January 2024. cdc.gov/nhsn/pdfs/ltc/ltcf-uti-protocol-current.pdf

National Health Care Safety Network. Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) events. NHSN. January 2025. cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf

Porat A, Bhutta BS, Kesler S. Urosepsis. StatPearls. 2025. ncbi.nlm.nih.gov/books/NBK482344/

Tocut M, Zohar I, Schwartz O, Yossepowitch O, Maor Y. Short- and long-term mortality in patients with urosepsis caused by Escherichia coli susceptible and resistant to 3rd generation cephalosporins. BMC Infect Dis. 2022;22(1):571. doi:10.1186/s12879-022-07538-5

Key words: urosepsis, urinary tract infection, long-term care, geriatric care