Abstract: OBJECTIVES: Infectious diseases are a major concern for patients dwelling in long-term care facilities and cause significant morbidity and mortality. Escherichia coli is a leading bacterial pathogen in this population, and infection can lead to invasive E coli disease (IED) such as complicated urinary tract infection (UTI) or sepsis. Despite this, IED has not been well characterized in the nursing home setting. Our objective is to present rates of complications and bacterial resistance patterns of IED in the nursing home population. DESIGN: This study is a retrospective cohort study. SETTING AND PARTICIPANTS: Long-stay residents of the Veterans Affairs-operated community living centers were monitored for E coli infections over a 3-year period. METHODS: Individuals with positive cultures for E coli were assessed for IED and further characterized based on site of infection and antibiotic resistance-testing results. RESULTS: Among 20,392 resident veterans, there were 10,175 E coli infections. Of those, 6840 infections met criteria for IED; 85% of IED cases met criteria for complicated UTI and 60% met criteria for Sepsis. Outcomes among cases of IED within 30 days of positive culture included hospitalization (23.5%), death (5.8%), and reinfection at the same site (12%). Cultures were tested and fluoroquinolone resistance was present in 52.7% of cases, cephalosporin resistance in 23.3%, and resistance to multiple classes of antibiotics in 12%. CONCLUSIONS AND IMPLICATIONS: The high prevalence of IED in this population along with concerning rates of complications emphasize that preventative interventions and treatments are a pressing need.