Urinary tract infections are the most common infection in nursing homes, with a prevalence rate of roughly 5.7% among residents over age 65. Respiratory infections, skin and soft tissue infections, and gastrointestinal illnesses round out the top four. Together, infections account for over 40% of all hospitalizations among nursing home residents, making them the single largest driver of emergency transfers from long-term care facilities.
Why UTIs Top the List
Urinary tract infections occur at a rate of 0.3 to 0.8 cases per 1,000 resident care days in long-term care settings. Several factors make them so prevalent. Many residents have difficulty fully emptying their bladders, use incontinence products, or have limited mobility that reduces bathroom access. Between 7% and 10% of nursing home residents have an indwelling urinary catheter, and that single device raises the risk of UTI by roughly 2.6 times. In one study, the rate of catheter-associated UTI was 5.5%, compared to just 1.1% for residents without a catheter. When catheters are in place, the incidence can spike as high as 7.43 per 1,000 resident care days.
Diagnosing UTIs in older adults is tricky because the classic symptoms of burning and urgency often don’t appear. Instead, a new onset of confusion, increased incontinence, or a sudden decline in the ability to perform daily tasks like dressing or eating may be the only signs. Standardized surveillance criteria used in nursing homes require both specific symptoms and a positive urine culture before labeling something a true UTI, partly because many older adults have bacteria in their urine without actually being infected.
Respiratory Infections: The Deadliest Type
Pneumonia and other lower respiratory infections are the second most common category, occurring at roughly 2.5 per 1,000 bed-days. While UTIs are more frequent, respiratory infections are far more dangerous. Short-term mortality from nursing home pneumonia ranges from 12% to 44%, with one large prospective study finding that 23% of residents who developed pneumonia died within 14 days. Even those who survived carried lasting consequences: 75% of pneumonia patients died within one year, compared to 40% of matched residents who never developed the infection. That excess mortality persisted for up to two years.
Swallowing difficulties, reduced cough reflexes, and spending long periods lying down all contribute to the high pneumonia rate in nursing homes. A resident who aspirates even small amounts of food or saliva repeatedly can develop infection deep in the lungs. Influenza also circulates easily in these close-quarter settings, and flu outbreaks frequently trigger secondary bacterial pneumonia. If current population trends hold, an estimated 2 million lower respiratory infections will occur annually among long-term care patients by 2030.
Skin and Soft Tissue Infections
Skin infections rank third, with a prevalence that ranges from 1% to 9% depending on the facility. Cellulitis, an infection of the deeper skin layers that causes redness, warmth, and swelling, is the most common type. Infected pressure ulcers come second. Roughly 20% to 25% of nursing home residents develop pressure ulcers at some point, and infections develop in up to 65% of those wounds. Residents with diabetes, poor circulation, or limited mobility face the highest risk.
Pennsylvania reporting data gives a useful snapshot of scale: facilities there recorded cellulitis at a rate of 12.68 per 100,000 resident days, while pressure ulcer infections occurred at 1.86 per 100,000 resident days. Though less immediately life-threatening than pneumonia, skin infections cause significant pain, slow rehabilitation, and often require prolonged courses of treatment that carry their own risks.
Gastrointestinal Infections and Outbreaks
Diarrheal illnesses round out the top four endemic infections, occurring at about 0.41 per 1,000 bed-days during normal surveillance periods. The bacterium C. difficile is a particular concern because it thrives after antibiotic use wipes out healthy gut bacteria. Nursing homes use a high volume of antibiotics relative to the general population, creating ideal conditions for C. difficile to spread. Norovirus is another major culprit, capable of sweeping through an entire facility within days. Gastrointestinal infections are the most common cause of epidemic outbreaks in nursing homes, alongside influenza and scabies.
Drug-Resistant Bacteria in Nursing Homes
One of the reasons infections are so dangerous in nursing homes is the presence of multidrug-resistant organisms. A study that swabbed residents’ hands, noses, and groin found that over one-third (36.5%) were colonized with at least one drug-resistant pathogen. The most common was vancomycin-resistant enterococci, found on 25.9% of residents. MRSA was detected on 8.6%, and resistant gram-negative bacteria on 13.7%.
These organisms spread readily through touch. When a resident’s hand carried MRSA, the pathogen was roughly 21 times more likely to transfer to nearby surfaces and equipment. VRE showed a nearly identical pattern. This means a single colonized resident can contaminate shared wheelchairs, bed rails, and call buttons during routine daily activities, seeding infections in others who may be far more vulnerable.
Why Nursing Home Residents Are So Vulnerable
Starting around age 60, the immune system undergoes a process called immunosenescence. The body’s adaptive immune response, the precise system that targets specific bacteria and viruses, gradually weakens. T cells lose their ability to repair damaged DNA and produce less energy at the cellular level, making them less effective at multiplying to fight off new threats. At the same time, the nonspecific inflammatory arm of the immune system becomes overactive, which leads to chronic low-grade inflammation that damages tissues without actually clearing infections.
Layer on top of that the specific conditions of nursing home life. Many residents have multiple chronic diseases, take numerous medications, use devices like catheters and feeding tubes, share living spaces and dining areas, and depend on staff who move from room to room throughout the day. Each of these factors independently raises infection risk. Combined, they create an environment where infections spread easily and hit harder than they would in the general older population.
The Cost of Infection in Long-Term Care
Infections don’t just affect individual residents. They drive a massive share of hospital transfers. In 2022 Medicare claims data, 41% of all hospitalizations among nursing home residents had a primary diagnosis of infection. Those infection-related stays were consistently worse by every measure: a median length of six days versus five for non-infection admissions, a median cost of $10,905 versus $8,051, double the rate of ICU admission (24% vs. 12%), and more than double the rate of death at discharge (14% vs. 6%).
Federal regulations now require every nursing home to maintain a formal infection prevention and control program. These programs must include systems for identifying, reporting, investigating, and controlling infections among residents, staff, volunteers, and visitors. Enhanced barrier precautions, such as wearing gowns and gloves during high-contact care for residents colonized with drug-resistant organisms, are among the more recent requirements aimed at slowing transmission between residents.