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uro.uti.uncomplicated.v1

Uncomplicated UTI (acute cystitis, non-pregnant adult)

urologyacuteadultoutpatientacute
Start encounter →Print handoutPRODUCTION

shard-3-neuro-sym Phase C 2026-05-14 — initial author at PRODUCTION with full §5.5 contract depth. 9 acuity / context phenotypes encoded as severity_triggers: acute_uncomplicated_cystitis, recurrent_uti, asymptomatic_bacteriuria, honeymoon_cystitis, catheter_associated_uti (route off), complicated_uti (route off), pyelonephritis_concern (route off), sti_overlap, resistant_or_esbl_e_coli. 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 + when to call PCP / ED) → outpatient (IDSA 2010 first-line empiric without routine UA / culture) → ed (severe symptoms + pyelo concern) → icu (urosepsis — RARE in uncomplicated; signals misclassification) → inpatient (non-responder pyelo + pregnancy complicated). IDSA 2010 first-line: nitrofurantoin 100 mg PO BID × 5 d (avoid if CrCl <30); fosfomycin 3 g PO × 1; TMP-SMX DS BID × 3 d if local resistance <20%. AVOID FQ first-line per FDA Black Box + IDSA collateral-damage doctrine. Pregnancy: cefpodoxime / cephalexin first-line. AVOID nitrofurantoin near term (G6PD neonatal hemolysis), sulfa near term (kernicterus), FQ throughout (cartilage). Asymptomatic bacteriuria MUST be treated in pregnancy (USPSTF 2019). Recurrent UTI (≥2/6mo or ≥3/12mo) — AUA 2022 prophylaxis: continuous low-dose nitrofurantoin / TMP-SMX OR post-coital single dose OR topical vaginal estrogen postmenopausal OR methenamine OR cranberry weak. Asymptomatic bacteriuria — treat ONLY in pregnancy or pre-urologic procedure (IDSA / USPSTF 2019); over-treatment drives resistance + C. difficile. Schema-blocked downstream: calc.uti_symptom_score (ACSS), protocol.uti_first_line_empiric, panel.local_antibiogram, uro.uti.complicated.v1, uro.pyelonephritis.v1, uro.cauti.v1 — none yet in clinical-tools-registry.ts. Tickets surfaced in docs/framework-audit/shard-3-neuro-sym-state.md. 2026-05-22 citation remediation — all prior PMIDs live-verified on PubMed; six were mis-attributed to unrelated articles and replaced with verified UTI anchors; RxCUIs reverse-verified on RxNav. Sibling pivots: symptom.hematuria.v1 (post-UTI hematuria persistence pivot), uro.urolithiasis.v1 (this commit — flank pain + dysuria overlap), id.cellulitis.core.v1 (Fournier adjacency stand-in) — all resolve to real engines in ALL_DOSSIERS.

Entry points (6)

  • symptom
    Dysuria + frequency + urgency in adult woman (IDSA 2010 PMID 21292654 — high PPV alone for cystitis)
    dysuria_frequency_urgency
  • symptom
    Suprapubic discomfort + cystitis symptoms (IDSA 2010)
    suprapubic_discomfort
  • symptom
    Gross hematuria + cystitis symptoms (still uncomplicated if no fever/flank pain) (IDSA 2010)
    gross_hematuria_with_cystitis
  • history
    Recurrent UTI (≥2/6mo or ≥3/12mo) → prophylaxis discussion (AUA 2022)
    recurrent_uti_pattern
  • lab_abnormality
    Positive urine culture without symptoms — treat ONLY in pregnancy or pre-urologic procedure (IDSA / USPSTF 2019)
    positive_culture_asymptomatic
  • symptom
    Post-coital UTI pattern → honeymoon cystitis; post-coital prophylaxis discussion (AUA 2022)
    post_coital_pattern

Required inputs (19)

  • sexrequired
    demographic • used at FRAME
    Engine scope is adult women; men require complicated UTI workup (anatomic / prostate concern) — route off (IDSA 2010)
  • pregnancy_statusrequired
    demographic • used at FRAME
    Pregnancy → complicated pathway; ASB must be treated; cephalosporin empirics; avoid nitrofurantoin near term + sulfa near term + FQ throughout (IDSA / USPSTF 2019)
  • agerequired
    demographic • used at CONTEXT
    Postmenopausal → topical vaginal estrogen consideration; <30 + sexual activity → STI panel if sterile pyuria (CDC 2021)
  • recent_antibioticsrequired
    history • used at CONTEXT
    Recent TMP-SMX (≤3 mo) → avoid empiric TMP-SMX; recent FQ → avoid FQ; broaden empirics if recent broad-spectrum (IDSA 2010)
  • diabetesrequired
    history • used at CONTEXT
    Poorly controlled DM → complicated UTI risk; consider culture and longer duration (IDSA 2010)
  • immunosuppressionrequired
    history • used at CONTEXT
    Immunocompromised → complicated UTI pathway; broaden empirics + culture (IDSA 2010)
  • anatomic_anomaly_or_stone_historyrequired
    history • used at CONTEXT
    Anatomic anomaly, prior stones, recent instrumentation → complicated pathway (IDSA 2010)
  • sexual_activity_recent
    history • used at CONTEXT
    Recent intercourse + dysuria → honeymoon cystitis pattern; STI panel if <30 + risk factors (CDC 2021)
  • prior_uti_count_6_to_12morequired
    history • used at CONTEXT
    ≥2/6mo or ≥3/12mo → recurrent UTI; prophylaxis discussion (AUA 2022)
  • menopause_status
    history • used at CONTEXT
    Postmenopausal → topical vaginal estrogen prophylaxis discussion (AUA 2022)
  • catheter_in_placerequired
    history • used at FRAME
    Indwelling catheter → CAUTI pathway (IDSA 2019); route off this engine
  • temprequired
    vital • used at RED_FLAGS
    Fever + flank pain → pyelonephritis pathway (route off engine to future pyelo engine); fever alone in cystitis is atypical (IDSA 2010)
  • flank_painrequired
    symptom • used at RED_FLAGS
    Flank pain → pyelonephritis pathway (IDSA 2010)
  • sbp
    vital • used at CONTEXT
    Hypotension + fever + dysuria → urosepsis ICU pathway (rare in uncomplicated — usually signals pyelo + obstruction)
  • urinalysis
    lab • used at INITIAL_WORKUP
    Leuk-esterase + nitrite confirm + sterile pyuria → STI / pyelo / TB pivot; not routinely required if classic presentation (IDSA 2010)
  • urine_culture
    lab • used at INITIAL_WORKUP
    Recurrent / pregnancy / treatment failure / atypical / male / DM poorly controlled → culture; not routine for classic uncomplicated cystitis (IDSA 2010)
  • creatininerequired
    lab • used at TREATMENT
    Dose adjustment — nitrofurantoin avoid if CrCl <30; dose adjust cefpodoxime / cephalexin if eGFR low (IDSA 2010)
  • sti_naat_panel
    lab • used at BRANCHING_WORKUP
    Sterile pyuria + <30 + sexual activity → NAAT chlamydia + gonorrhea + trichomonas (CDC 2021)
  • current_medsrequired
    medication • used at TREATMENT
    Anticoagulant + nitrofurantoin interaction; methotrexate + sulfa toxicity; warfarin + sulfa INR rise (IDSA 2010)

12-phase flow (12)

  1. 1FRAME
    Non-pregnant adult woman with dysuria + frequency + urgency — acute uncomplicated cystitis differential. Explicit pivots OFF engine for: pregnancy, men, immunocompromised, anatomic anomaly, catheter, fever + flank pain (IDSA 2010)
    inputs: sex, pregnancy_status, catheter_in_place
    advance: engine scope confirmed
  2. 2ENTRY
    Dysuria + frequency + urgency ± suprapubic discomfort ± hematuria; rule in cystitis (IDSA 2010)
    inputs: age
    advance: entry captured
  3. 3CONTEXT
    Pregnancy, recent abx, DM, immunocompromise, anatomic anomaly, sexual activity, prior UTI history, menopause, sexual activity, STI risk (IDSA 2010; CDC 2021; AUA 2022)
    inputs: recent_antibiotics, diabetes, immunosuppression, anatomic_anomaly_or_stone_history, sexual_activity_recent, prior_uti_count_6_to_12mo, menopause_status, current_meds
    advance: context complete; engine still applies
  4. 4RED_FLAGS
    Fever + flank pain → pyelonephritis (route off engine); hemodynamic instability → urosepsis ICU; pregnancy → complicated pathway; immunocompromise → broaden (IDSA 2010)
    inputs: temp, flank_pain, sbp
    advance: no red flags OR route off
  5. 5INITIAL_WORKUP
    NOT routinely required if classic presentation in healthy non-pregnant woman (IDSA 2010 — symptoms alone have high PPV). UA + culture if pregnancy / recurrent / atypical / treatment failure (IDSA 2010)
    inputs: urinalysis, urine_culture
    actions: panel.ua, panel.renal
    advance: workup tier selected
  6. 6BRANCHING_WORKUP
    Sterile pyuria → STI / pyelo / TB / contamination pivot; recurrent → prophylaxis discussion; pregnancy → cephalosporin empirics; resistant E. coli → broaden (IDSA 2010; CDC 2021)
    inputs: sti_naat_panel
    advance: pivot or proceed to treatment
  7. 7DIFFERENTIAL
    Uncomplicated cystitis vs complicated UTI (route off) vs pyelonephritis (route off) vs vaginitis vs urethritis (STI) vs interstitial cystitis vs renal colic vs hematuria workup (real symptom.hematuria.v1) (IDSA 2010)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    IDSA 2010 uncomplicated criteria; local E. coli resistance to TMP-SMX (>20% → avoid); recurrent UTI tier (≥2/6mo or ≥3/12mo) → prophylaxis (IDSA 2010; AUA 2022)
    inputs: creatinine
    advance: regimen tier selected
  9. 9TREATMENT
    First-line: nitrofurantoin 100 mg PO BID × 5 d (avoid if CrCl <30) OR fosfomycin 3 g PO × 1 OR TMP-SMX DS BID × 3 d if R <20%. AVOID FQ first-line per FDA Black Box. Pregnancy: cefpodoxime / cephalexin. Recurrent: prophylaxis (continuous, post-coital, topical estrogen, methenamine, cranberry weak) (IDSA 2010; AUA 2022)
    inputs: creatinine
    advance: regimen prescribed
  10. 10DISPOSITION
    Outpatient discharge with 48 h re-check if no improvement; rare admission only for pyelo / sepsis / pregnancy obstruction (IDSA 2010)
    advance: disposition documented
  11. 11MONITORING
    Symptom resolution by 48–72 h; if persists → culture-directed therapy; reassess for pyelonephritis if fever / flank pain develops (IDSA 2010)
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Recurrent UTI → prophylaxis options (continuous low-dose, post-coital, topical vaginal estrogen postmenopausal, methenamine, cranberry weak per AUA 2022); urology referral if breakthrough on prophylaxis (AUA 2022)
    advance: follow-up + prophylaxis scheduled if recurrent