Missed Sepsis or Over-Treated Urine? Getting Infection Calls Right

Infection decisions in a nursing home can go wrong in two opposite directions. A resident who is quietly becoming septic can be missed because there is no fever. And a resident with a positive urine culture but no real urinary symptoms can be labeled with a "UTI" and started on antibiotics that do not help and can cause harm.

Both mistakes lead to avoidable hospital transfers. The fix is the same for both: careful observation, clear documentation and a shared language for what counts as a change.

Why Infection Looks Different in Older Adults

CDC notes that standard sepsis criteria may work less well in older adults. Residents may not develop a fever, and cognitive changes or chronic conditions can hide or mimic infection. CDC's guidance for long-term care asks staff to watch for changes from the resident's usual baseline rather than wait for a classic picture.

The revised McGeer surveillance criteria reflect the same idea. The authors lowered the fever threshold for older residents because they often mount a weaker fever response. Under those criteria, fever includes a single oral temperature above 100°F (37.8°C), repeated oral temperatures above 99°F (37.2°C), or a single temperature more than 2°F (1.1°C) above the resident's baseline.

Changes Worth Reporting the Same Shift

CDC's sepsis fact sheet for long-term care nurses and its resident-safety page list changes that should prompt a call to the provider. Report these promptly and follow your facility's sepsis process:

• New or increased confusion or disorientation
• A high heart rate or low blood pressure
• Fever, shivering, or feeling very cold
• Shortness of breath or a faster breathing rate
• Clammy or sweaty skin, or extreme pain or discomfort
• Loss of appetite or reduced eating and drinking
• New trouble getting out of bed, or needing help with tasks the resident usually does alone

CDC is direct about urgency: if sepsis is suspected, alert the overseeing provider immediately, and expect that the resident will often need quick transfer to a hospital. A clear, fast report gives the provider what they need to decide.

The Other Side: A Positive Culture Is Not Always an Infection

Many nursing home residents have bacteria in their urine without infection. This is called asymptomatic bacteriuria. The 2019 Infectious Diseases Society of America (IDSA) guideline recommends against screening for or treating asymptomatic bacteriuria in older residents of long-term care facilities.

The guideline also addresses two situations that come up every week. For older residents with functional or cognitive impairment who have bacteriuria and delirium, or who have a fall, but no local urinary symptoms and no systemic signs of infection, it recommends assessing for other causes and careful observation rather than treating the urine. The same guideline notes that a resident with fever or unstable vital signs and no clear source is a different situation and needs prompt evaluation for possible sepsis.

In practice, new confusion should prompt a full look at the resident, not just a urine test.

Surveillance Criteria Give Everyone the Same Yardstick

Two tools help teams talk about urinary infections consistently.

• Loeb minimum criteria were developed by an expert consensus group in 2001 to guide when antibiotics might be started in long-term care. For a resident without a catheter, they look for acute painful urination, or fever plus at least one new urinary sign such as urgency, frequency, suprapubic pain, visible blood in the urine, flank tenderness or new incontinence. Providers and stewardship teams use them; nurses help by documenting each element clearly.
• Revised McGeer criteria (2012) are surveillance definitions for infection tracking. They require both compatible symptoms and specific culture results. The authors state plainly that these are for surveillance and may not be adequate for real-time diagnosis or treatment decisions.

Neither tool replaces the provider's judgment. Their value is a shared language across the team.

How Stewardship Ties It Together

CDC's Core Elements of Antibiotic Stewardship for Nursing Homes recommends that every facility work to improve antibiotic use. The seven elements are leadership commitment, accountability, drug expertise, action, tracking, reporting and education. CDC cites studies suggesting that 40% to 75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate, and it names asymptomatic bacteriuria as one situation that drives inappropriate courses.

Stewardship does not mean withholding care. It means the right evaluation for the right resident, with sepsis recognized fast and positive cultures read in context.

What to Do This Week

• Post CDC's long-term care sepsis fact sheet at each nurses' station and review it in a huddle.
• Make sure each resident's baseline temperature, mental status and function are documented so changes are easy to spot.
• When calling a provider about possible infection, report vital signs, mental status, intake and any urinary symptoms, not just a culture result.
• Ask your infection preventionist to share how Loeb or McGeer criteria are used in your building.
• Review how urine cultures are ordered: is there a symptom check before a specimen is sent?

A daily risk screen can help teams notice baseline changes earlier, which is part of how Keystone supports nursing staff.

This article is general education for skilled nursing teams. Follow your facility's policies and the direction of your medical director and providers.