shard-3-neuro-sym Phase C wave-7 2026-05-15 — initial author at INTEGRATED with full §5.5 contract depth. 9 acuity / context phenotypes encoded as severity_triggers: uncomplicated_outpatient_pyelo, uncomplicated_inpatient_pyelo, complicated_pyelo, urosepsis_with_obstruction (the central operational emergency), emphysematous_pyelo, renal_perinephric_abscess, pregnancy_pyelo, xanthogranulomatous_pyelo, acute_lobar_nephronia, esbl_or_mdr_pyelo. Pivot from sibling rows because per-phenotype dossiers do not exist (same engine, different management branch). 5 setting playbooks span the full journey: home (recognition + ED routing) → outpatient (IDSA 2010 FQ-eligible 5–7 d) → ed (STAT UA + culture + blood culture + lactate + renal US + triage) → inpatient (IV ceftriaxone × 24–72 h then PO step-down; total 7–14 d) → icu (urosepsis with shock + obstruction — SCC 2026 bundle + STAT decompression). IDSA 2010 outpatient first-line: ciprofloxacin 500 mg PO BID × 7 d OR levofloxacin 750 mg PO daily × 5 d if local FQ resistance <10%; initial IV ceftriaxone 1 g × 1 then oral step-down if FQ R >10%; TMP-SMX DS BID × 14 d if susceptible alternative. IDSA 2010 inpatient: IV ceftriaxone 1 g q24h × 24–72 h until afebrile + PO tolerance, then PO step-down per culture; total 7–14 d course. ESBL → ertapenem 1 g IV q24h (Tamma IDSA 2019); carbapenem-sparing principle — reserve meropenem for severe / non-ertapenem susceptible. Pseudomonas concern (healthcare-associated, prior MDR, immunocompromised) → cefepime 2 g IV q8h OR pip-tazo 4.5 g IV q6h. Pregnancy → admit + IV ceftriaxone 1 g q24h; PO step-down cephalexin × 10–14 d total; AVOID FQ throughout (cartilage), AVOID nitrofurantoin (no renal penetration regardless of trimester), AVOID sulfa near term. Emphysematous pyelo (gas in parenchyma on CT in diabetic) → STAT urology + IR for drainage / nephrectomy; broad-spectrum (pip-tazo or cefepime + metronidazole); high mortality without source control. Renal / perinephric abscess (CT or US) → percutaneous drainage + 4–6 wk culture-directed abx. AVOID-NITROFURANTOIN-IN-PYELO doctrine — load-bearing distinction from cystitis; nitrofurantoin concentrates in urine but NOT renal tissue (IDSA 2010). AVOID-FQ-IN-PREGNANCY doctrine — cartilage toxicity throughout pregnancy (FDA). Source control mandatory for obstruction (PCN / stent), abscess (drainage), emphysematous pyelo (drainage or nephrectomy), XGP (nephrectomy) (EAU 2020). Schema-blocked downstream: calc.qsofa_pyelo, protocol.pyelo_iv_to_po_bridge, uro.cauti.v1, uro.emphysematous-pyelo.v1, uro.renal-abscess.v1, uro.xgp.v1 — none yet in clinical-tools-registry.ts. Tickets surfaced in depth brief §9. 2026-05-22 citation remediation — all PMIDs live-verified on PubMed; mis-attributed placeholders replaced with verified anchors; RxCUIs reverse-verified on RxNav. Sibling pivots: uro.uti.uncomplicated.v1 (cystitis — nitrofurantoin pivot), symptom.fuo.v1 (FUO differential when no urinary sx), id.sepsis.core.v1 (urosepsis is most common gram-negative sepsis source) — all resolve to real engines in ALL_DOSSIERS. Dossier NOT registered in _registry.ts per shard scope (DO NOT TOUCH _registry.ts). Registration deferred to subsequent commit by shard-0 / cross-shard registry maintainer.