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uro.uti.complicated.v1

Complicated UTI (men, pregnant, catheter, anatomic, IC, ESBL/MDR, fungal, prostatitis overlay)

urologyacuteadultpregnancygeriatricoutpatientacuteinpatient
Start encounter →Print handoutPRODUCTION

shard-3-neuro-sym Phase C wave-7 2026-05-15 — initial author at INTEGRATED with full §5.5 contract depth. 10 acuity / context phenotypes encoded as severity_triggers: men_with_uti (always complicated), pregnant_uti, cauti, immunocompromised_uti, diabetic_uti, anatomic_abnormality_uti, recurrent_breakthrough, esbl_or_mdr_uti, candiduria, prostatitis_overlay. 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 + complicating-factor routing) → outpatient (culture-required broader empirics) → ed (STAT UA + culture + triage + CAUTI catheter management) → inpatient (IV ceftriaxone × 24–72 h then PO step-down; total 10–14 d) → icu (urosepsis with shock — mirrors pyelo ICU pathway). Empiric outpatient: cefpodoxime 100 mg PO BID × 7–14 d OR cefdinir 300 mg PO BID OR cephalexin 500 mg PO QID. Men with UTI = always complicated → cipro 500 mg PO BID × 7–14 d OR TMP-SMX DS BID × 7–14 d + workup obstruction + DRE. ESBL → ertapenem 1 g IV q24h × 7–14 d (Tamma IDSA 2020); CRE → ID consult + novel agents (ceftazidime-avibactam, meropenem-vaborbactam, plazomicin) per susceptibility. CAUTI → remove catheter when possible; treat ONLY if symptomatic; do NOT treat ASB in catheterized patients (IDSA 2019 PMID 20175247). Pregnancy → cefpodoxime / cephalexin × 7 d; treat ASB even without symptoms; AVOID FQ throughout (cartilage); admit + IV ceftriaxone if pyelo or sepsis (USPSTF 2019). Candiduria → fluconazole 200–400 mg PO daily × 14 d ONLY if symptomatic / IC / pre-procedure; do NOT treat asymptomatic candiduria (drives resistance). Prostatitis overlay (men + UTI + prostate localisation) → cipro 500 mg PO BID OR TMP-SMX DS BID × 4–6 wk (acute) or 6–12 wk (chronic); FQ has prostate penetration; prolonged course increases FDA Black Box risk. ASB DO-NOT-TREAT doctrine — treat ONLY in pregnancy or pre-urologic procedure with mucosal trauma (USPSTF / IDSA 2019). Schema-blocked downstream: uro.cauti.v1, uro.prostatitis.v1, uro.candiduria.v1, calc.uti_complicated_severity, protocol.cauti_remove_catheter_pivot, workup.dre_prostate_exam — none yet in clinical-tools-registry.ts. Tickets surfaced in depth brief §11. 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 (simple — any complicating factor routes here), uro.pyelonephritis.v1 (this commit — upper-tract pivot), symptom.hematuria.v1 (post-UTI hematuria persistence) — 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.

Entry points (8)

  • symptom
    Dysuria / frequency / urgency + complicating factor (man, pregnant, catheter, IC, anatomic anomaly) (IDSA 2010 Gupta PMID 21292654)
    dysuria_frequency_in_complicated_host
  • demographic
    Adult male with UTI — always complicated (IDSA 2010)
    male_sex_with_uti
  • demographic
    Pregnancy + UTI or ASB — treat (USPSTF 2019)
    pregnancy_with_uti_or_asb
  • history
    Catheter-associated UTI (CAUTI) with symptoms (IDSA 2019 PMID 20175247)
    indwelling_catheter_with_symptoms
  • lab_abnormality
    Prior or current ESBL / CRE / MDR culture (Tamma IDSA 2020)
    positive_culture_esbl_or_mdr
  • lab_abnormality
    Candiduria + symptomatic OR immunocompromised OR pre-procedure (IDSA 2009 candiduria update)
    candiduria_with_symptoms_or_IC
  • history
    Recurrent UTI breakthrough despite prophylaxis (AUA 2022)
    recurrent_uti_breakthrough_on_prophylaxis
  • symptom
    Man with UTI + prostate tenderness on DRE OR perineal pain — prostatitis overlay (IDSA 2010)
    prostate_tender_or_perineal_pain_men

Required inputs (23)

  • sexrequired
    demographic • used at FRAME
    Men with UTI = always complicated; workup obstruction + DRE; FQ × 7–14 d or TMP-SMX (IDSA 2010)
  • pregnancy_statusrequired
    demographic • used at FRAME
    Pregnancy + UTI / ASB → cephalosporin × 7 d; AVOID FQ throughout; admit if pyelo or sepsis (USPSTF 2019; IDSA 2010)
  • agerequired
    demographic • used at CONTEXT
    Geriatric (≥65) → atypical presentation (altered mental status), dose adjustments; pediatric routes off engine (AAP)
  • catheter_in_placerequired
    history • used at FRAME
    CAUTI pathway — remove catheter when possible; treat ONLY if symptomatic; replace before culture if retained (IDSA 2019)
  • immunosuppressionrequired
    history • used at CONTEXT
    SOT, hematologic malignancy, HIV with low CD4, chronic steroid → broader empirics; ID consult (IDSA 2010)
  • diabetesrequired
    history • used at CONTEXT
    Poorly controlled DM → emphysematous pyelo risk; culture; longer duration (EAU 2020)
  • anatomic_anomaly_or_stonesrequired
    history • used at CONTEXT
    Stricture, neurogenic bladder, reflux, calculi → workup + urology referral (AUA 2016)
  • recurrent_uti_countrequired
    history • used at CONTEXT
    Recurrent breakthrough on prophylaxis → urology referral + switch prophylaxis (AUA 2022)
  • recent_antibioticsrequired
    history • used at CONTEXT
    Recent FQ → avoid empiric FQ; recent broad → ESBL / Pseudomonas concern (Tamma 2019)
  • prior_esbl_or_mdr_culturerequired
    history • used at CONTEXT
    Prior ESBL → empiric ertapenem; prior CRE → ID consult (Tamma 2019)
  • transplant_status
    history • used at CONTEXT
    Renal transplant or other SOT → ID + transplant team co-management (IDSA)
  • sexual_activity_recent_men_lt_35
    history • used at CONTEXT
    Sexually active man <35 + dysuria → STI panel (CDC 2021)
  • temprequired
    vital • used at RED_FLAGS
    Fever + flank pain → pyelo pathway (route off engine to uro.pyelonephritis.v1)
  • flank_painrequired
    symptom • used at RED_FLAGS
    Flank pain → pyelo pathway (IDSA 2010)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension + fever → urosepsis ICU (SCC 2026)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Leuk-esterase + nitrite confirm; sterile pyuria → STI / TB / candiduria pivot (IDSA 2010)
  • urine_culturerequired
    lab • used at INITIAL_WORKUP
    ALWAYS in complicated UTI before abx (IDSA 2010)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis → severity; thrombocytopenia → sepsis (SCC 2026)
  • bmprequired
    lab • used at INITIAL_WORKUP
    AKI staging + dose adjustment (KDIGO AKI 2026)
  • pregnancy_hcgrequired
    lab • used at INITIAL_WORKUP
    Reproductive-age women — drives regimen (USPSTF 2019)
  • renal_us_if_obstruction_or_anatomic
    imaging • used at INITIAL_WORKUP
    Renal US if obstruction / stone / anatomic concern (AUA 2016; EAU 2020)
  • sti_naat_panel_men_lt_35
    lab • used at BRANCHING_WORKUP
    Young sexually active man + dysuria → NAAT chlamydia + gonorrhea + trichomonas (CDC 2021)
  • current_medsrequired
    medication • used at TREATMENT
    Anticoagulant + sulfa INR; methotrexate + sulfa toxicity; FQ + steroid → tendinopathy (FDA)

12-phase flow (12)

  1. 1FRAME
    UTI symptoms + ≥1 complicating factor (man, pregnant, catheter, IC, anatomic, recurrent, ESBL/MDR, IC, candiduria, prostatitis) → complicated UTI pathway. Pivot: fever + flank pain → uro.pyelonephritis.v1; none of complicating factors → uro.uti.uncomplicated.v1 (IDSA 2010)
    inputs: sex, pregnancy_status, catheter_in_place
    advance: engine scope confirmed
  2. 2ENTRY
    Dysuria / frequency / urgency / suprapubic ± hematuria + complicating factor; rule in complicated UTI (IDSA 2010)
    inputs: age
    advance: entry captured
  3. 3CONTEXT
    Sex (men always complicated), pregnancy, catheter, anatomic anomaly, immunocompromise, DM, transplant, recurrent breakthrough, recent abx, prior MDR / ESBL, sexual activity (STI overlap), candiduria (IDSA 2010; IDSA 2019; AUA 2022; Tamma 2019; CDC 2021)
    inputs: immunosuppression, diabetes, anatomic_anomaly_or_stones, recurrent_uti_count, recent_antibiotics, prior_esbl_or_mdr_culture, transplant_status, sexual_activity_recent_men_lt_35, current_meds
    advance: context complete
  4. 4RED_FLAGS
    Fever + flank pain → pyelo (route off engine); hypotension / sepsis → ICU; obstruction → STAT decompression; pregnancy + fever → admit (IDSA 2010; SCC 2026)
    inputs: temp, flank_pain, sbp
    advance: no red flags OR route off
  5. 5INITIAL_WORKUP
    STAT UA + urine culture (always) + CBC + BMP + pregnancy test; renal US if anatomic / obstruction concern; STI panel for young sexually active men (IDSA 2010; CDC 2021)
    inputs: urinalysis, urine_culture, cbc, bmp, pregnancy_hcg, renal_us_if_obstruction_or_anatomic
    actions: panel.ua, panel.renal, panel.cbc
    advance: workup complete
  6. 6BRANCHING_WORKUP
    Men + UTI → workup obstruction + DRE + prostatitis pivot; pregnancy → OB co-management; CAUTI → remove catheter; candiduria → treat only if symptomatic / IC / pre-procedure; ESBL → ertapenem (IDSA 2010; IDSA 2019; Tamma 2019)
    inputs: sti_naat_panel_men_lt_35
    advance: pathway selected
  7. 7DIFFERENTIAL
    Complicated UTI vs prostatitis (men) vs pyelo vs CAUTI vs candiduria vs STI urethritis vs interstitial cystitis vs anatomic obstruction (IDSA 2010)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    Complicated criteria checklist; sepsis screen (qSOFA); CrCl for dosing; prior ESBL → empiric carbapenem-class (Tamma 2019; SCC 2026)
    advance: tier selected
  9. 9TREATMENT
    Empiric broader than uncomplicated; cefpodoxime / cefdinir / cephalexin × 7–14 d outpatient; men FQ × 7–14 d (or TMP-SMX); ESBL → ertapenem; MDR → tailored; CAUTI → remove catheter; pregnancy → cephalosporin; candiduria → fluconazole if indicated; prostatitis → 4–6 wk FQ or TMP-SMX (IDSA 2010; IDSA 2019; Tamma 2019)
    inputs: current_meds
    advance: regimen prescribed
  10. 10DISPOSITION
    Outpatient if PO-tolerant + low-risk; admit if pregnancy + pyelo / sepsis / obstruction / non-PO; ICU if urosepsis (IDSA 2010; SCC 2026)
    advance: disposition documented
  11. 11MONITORING
    Symptom resolution at 48–72 h; culture follow-up; pregnancy → repeat culture at 1–2 wk; recurrent → urology workup (IDSA 2010; AUA 2022)
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Urology if anatomic / recurrent / men; prophylaxis discussion if recurrent; counsel prostatitis recurrence in men; remove catheter when possible (AUA 2022; IDSA 2019)
    advance: follow-up scheduled