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uro.uti.uncomplicated.v1

Uncomplicated UTI (acute cystitis, non-pregnant adult)

urologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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engine scope confirmed

Patient inputs (19)

Postmenopausal → topical vaginal estrogen consideration; <30 + sexual activity → STI panel if sterile pyuria (CDC 2021)

Recent TMP-SMX (≤3 mo) → avoid empiric TMP-SMX; recent FQ → avoid FQ; broaden empirics if recent broad-spectrum (IDSA 2010)

Poorly controlled DM → complicated UTI risk; consider culture and longer duration (IDSA 2010)

Immunocompromised → complicated UTI pathway; broaden empirics + culture (IDSA 2010)

Anatomic anomaly, prior stones, recent instrumentation → complicated pathway (IDSA 2010)

≥2/6mo or ≥3/12mo → recurrent UTI; prophylaxis discussion (AUA 2022)

Engine scope is adult women; men require complicated UTI workup (anatomic / prostate concern) — route off (IDSA 2010)

Pregnancy → complicated pathway; ASB must be treated; cephalosporin empirics; avoid nitrofurantoin near term + sulfa near term + FQ throughout (IDSA / USPSTF 2019)

Indwelling catheter → CAUTI pathway (IDSA 2019); route off this engine

Fever + flank pain → pyelonephritis pathway (route off engine to future pyelo engine); fever alone in cystitis is atypical (IDSA 2010)

Flank pain → pyelonephritis pathway (IDSA 2010)

Dose adjustment — nitrofurantoin avoid if CrCl <30; dose adjust cefpodoxime / cephalexin if eGFR low (IDSA 2010)

Anticoagulant + nitrofurantoin interaction; methotrexate + sulfa toxicity; warfarin + sulfa INR rise (IDSA 2010)

Sterile pyuria + <30 + sexual activity → NAAT chlamydia + gonorrhea + trichomonas (CDC 2021)

Recent intercourse + dysuria → honeymoon cystitis pattern; STI panel if <30 + risk factors (CDC 2021)

Postmenopausal → topical vaginal estrogen prophylaxis discussion (AUA 2022)

Hypotension + fever + dysuria → urosepsis ICU pathway (rare in uncomplicated — usually signals pyelo + obstruction)

Leuk-esterase + nitrite confirm + sterile pyuria → STI / pyelo / TB pivot; not routinely required if classic presentation (IDSA 2010)

Recurrent / pregnancy / treatment failure / atypical / male / DM poorly controlled → culture; not routine for classic uncomplicated cystitis (IDSA 2010)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationalseverepyelonephritis_concern
    Fever + flank pain + N/V + dysuria — pyelonephritis pathway; route OFF engine to future `uro.pyelonephritis.v1` (IDSA 2010)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_uti
    Recurrent UTI (≥2 episodes / 6 mo OR ≥3 / 12 mo) — prophylaxis discussion indicated (AUA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehoneymoon_cystitis
    Post-coital UTI pattern (recurrent within days of intercourse) — counsel + post-coital prophylaxis discussion (AUA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecatheter_associated_uti
    Patient with indwelling catheter — CAUTI pathway (IDSA 2019 PMID 20175247); route OFF engine
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecomplicated_uti
    Men, pregnant, immunocompromised, anatomic anomaly, recurrent breakthrough, poorly controlled DM, anatomic obstruction — complicated UTI pathway; route OFF engine to future `uro.uti.complicated.v1`
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesti_overlap
    Sterile pyuria + age <30 + sexual activity + dysuria — STI overlap; CDC 2021 STI panel + empiric coverage if positive
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateresistant_or_esbl_e_coli
    Prior culture-resistant E. coli OR healthcare exposure OR recent FQ — avoid empiric TMP-SMX / FQ; pip-tazo / carbapenem if ESBL + severe (IDSA 2010)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildacute_uncomplicated_cystitis
    Non-pregnant adult woman with dysuria + frequency + urgency without fever / flank pain — classic acute uncomplicated cystitis (IDSA 2010 Gupta PMID 21292654)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildasymptomatic_bacteriuria
    Positive urine culture WITHOUT urinary symptoms — treat ONLY in pregnancy or pre-urologic procedure (IDSA / USPSTF 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Uncomplicated UTI — IDSA 2010 first-line empirics + pregnancy regimen + recurrent UTI prophylaxis (AUA 2022)
axis: uti_uncomplicated_empiric_and_prophylaxisstep 1 - First-line empiric (non-pregnant adult women, IDSA 2010)
Selected step "First-line empiric (non-pregnant adult women, IDSA 2010)" — Classic acute uncomplicated cystitis in non-pregnant healthy adult woman without recent abx exposure
  • nitrofurantoin
    first line
    nitrofuran_antibiotic
    100 mg PO BID • PO • BID × 5 days (max: 100 mg BID)
    triggers: acute_uncomplicated_cystitis, CrCl_ge_30, no_pyelonephritis_concern
    IDSA 2010 first-line — bactericidal in urine; minimal collateral damage; AVOID if CrCl <30 (insufficient urinary concentration) and AVOID in pyelonephritis (does not concentrate in renal tissue) (Gupta PMID 21292654)
    rxcui 7454
  • fosfomycin
    first line
    phosphonic_acid_antibiotic
    3 g PO × 1 dose • PO • single dose
    triggers: single_dose_preference, compliance_concern
    IDSA 2010 first-line single-dose convenience; lower 5-d cure rate than nitrofurantoin per Cochrane (Gupta PMID 21292654)
    rxcui 4550
  • trimethoprim-sulfamethoxazole
    first line
    sulfa_antibiotic
    160/800 mg (DS) PO BID • PO • BID × 3 days
    triggers: local_E_coli_resistance_lt_20pct, no_recent_TMP_SMX_exposure, no_sulfa_allergy
    IDSA 2010 first-line ONLY if local E. coli resistance <20% AND no recent (≤3 mo) TMP-SMX exposure (Gupta PMID 21292654)
    rxcui 10831

outpatient playbook — drug actions (5)

  1. 1. nitrofurantoin
    100 mg PO BID × 5 d • PO • BID
    trigger: First-line — classic uncomplicated cystitis, CrCl ≥30, no contraindication
    IDSA 2010 first-line (Gupta PMID 21292654)
  2. 2. fosfomycin
    3 g PO × 1 • PO • single dose
    trigger: Single-dose preference or compliance concern
    IDSA 2010 first-line single-dose alternative
  3. 3. TMP-SMX
    160/800 mg PO BID × 3 d • PO • BID
    trigger: Local resistance <20% + no recent exposure + no sulfa allergy
    IDSA 2010 first-line if resistance criteria met
  4. 4. cefpodoxime / cephalexin
    Cefpodoxime 100 mg PO BID × 5–7 d OR cephalexin 500 mg PO QID × 5–7 d • PO • BID / QID
    trigger: First-line contraindicated or pregnancy
    IDSA 2010 second-line + pregnancy first-line
  5. 5. phenazopyridine (adjunct)
    100–200 mg PO TID × ≤2 d • PO • TID × ≤2 d
    trigger: Symptomatic bladder discomfort
    Symptomatic adjunct only; orange urine warning; AVOID G6PD

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Dysuria + frequency + urgency in adult woman (IDSA 2010 PMID 21292654 — high PPV alone for cystitis); Suprapubic discomfort + cystitis symptoms (IDSA 2010); Gross hematuria + cystitis symptoms (still uncomplicated if no fever/flank pain) (IDSA 2010).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Uncomplicated UTI (acute cystitis, non-pregnant adult)** (uro.uti.uncomplicated.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Uncomplicated UTI — IDSA 2010 first-line empirics + pregnancy regimen + recurrent UTI prophylaxis (AUA 2022)** — step "First-line empiric (non-pregnant adult women, IDSA 2010)".
1. nitrofurantoin 100 mg PO BID PO BID × 5 days (nitrofuran_antibiotic, first line) — IDSA 2010 first-line — bactericidal in urine; minimal collateral damage; AVOID if CrCl <30 (insufficient urinary concentration) and AVOID in pyelonephritis (does not concentrate in renal tissue) (Gupta PMID 21292654)
2. fosfomycin 3 g PO × 1 dose PO single dose (phosphonic_acid_antibiotic, first line) — IDSA 2010 first-line single-dose convenience; lower 5-d cure rate than nitrofurantoin per Cochrane (Gupta PMID 21292654)
3. trimethoprim-sulfamethoxazole 160/800 mg (DS) PO BID PO BID × 3 days (sulfa_antibiotic, first line) — IDSA 2010 first-line ONLY if local E. coli resistance <20% AND no recent (≤3 mo) TMP-SMX exposure (Gupta PMID 21292654)

Setting playbook (outpatient) — Empiric first-line nitrofurantoin × 5 d (or fos / TMP-SMX per local resistance) WITHOUT routine UA / culture if classic presentation in healthy non-pregnant woman; culture if pregnant / recurrent / treatment failure / atypical / male / poorly controlled DM (IDSA 2010)
4. nitrofurantoin 100 mg PO BID × 5 d PO BID — First-line — classic uncomplicated cystitis, CrCl ≥30, no contraindication (IDSA 2010 first-line (Gupta PMID 21292654))
5. fosfomycin 3 g PO × 1 PO single dose — Single-dose preference or compliance concern (IDSA 2010 first-line single-dose alternative)
6. TMP-SMX 160/800 mg PO BID × 3 d PO BID — Local resistance <20% + no recent exposure + no sulfa allergy (IDSA 2010 first-line if resistance criteria met)
7. cefpodoxime / cephalexin Cefpodoxime 100 mg PO BID × 5–7 d OR cephalexin 500 mg PO QID × 5–7 d PO BID / QID — First-line contraindicated or pregnancy (IDSA 2010 second-line + pregnancy first-line)
8. phenazopyridine (adjunct) 100–200 mg PO TID × ≤2 d PO TID × ≤2 d — Symptomatic bladder discomfort (Symptomatic adjunct only; orange urine warning; AVOID G6PD)

Non-pharmacologic actions:
- Patient education — symptom trajectory + when to call (fever / flank pain / no improvement at 48–72 h)
- Recurrent UTI counselling if applicable — prophylaxis options (AUA 2022)
- Postmenopausal women — topical vaginal estrogen discussion if recurrent (AUA 2022)
- Behavioural counselling — voiding after intercourse, hydration (weak evidence; AUA 2022)

AVOID / contraindication checks:
- Nitrofurantoin_avoid_if_CrCl_lt_30 (IDSA 2010 Gupta PMID 21292654)
- Nitrofurantoin_avoid_in_pyelonephritis_does_not_concentrate_in_renal_tissue (IDSA 2010)
- Nitrofurantoin_avoid_in_3rd_trimester_near_term_G6PD_neonatal_hemolysis (IDSA / USPSTF)
- Nitrofurantoin_pulmonary_fibrosis_chronic_use_monitor (FDA)
- TMP_SMX_avoid_if_local_resistance_ge_20pct (IDSA 2010)
- TMP_SMX_avoid_if_recent_exposure_le_3mo (IDSA 2010)
- TMP_SMX_avoid_near_term_pregnancy_sulfa_kernicterus (USPSTF)
- TMP_SMX_interaction_with_warfarin_INR_rise (IDSA 2010)
- TMP_SMX_interaction_with_methotrexate_toxicity (IDSA 2010)
- Fluoroquinolones_NEVER_first_line_uncomplicated_FDA_black_box (FDA 2016+)
- Fluoroquinolones_avoid_throughout_pregnancy_cartilage (FDA)
- Fluoroquinolones_tendinopathy_CNS_dysglycemia_aortic_aneurysm_elderly (FDA)
- Fosfomycin_lower_efficacy_than_5d_nitrofurantoin_Cochrane (Gupta 2010)
- Phenazopyridine_avoid_in_G6PD_deficiency_methemoglobinemia (FDA)
- Asymptomatic_bacteriuria_DO_NOT_TREAT_except_pregnancy_or_pre_procedure (IDSA / USPSTF 2019)
- Methenamine_avoid_if_renal_or_hepatic_impairment (AUA 2022)
- Topical_vaginal_estrogen_breast_ca_history_use_after_oncologist_consult (AUA 2022)

Monitoring

Regimen monitoring:
- symptom resolution by 48 to 72h (IDSA 2010)
- urine culture if treatment failure at 48 to 72h (IDSA 2010)
- reassess for pyelonephritis if fever or flank pain develops (IDSA 2010)
- long term nitrofurantoin monitor pulmonary fibrosis LFTs (FDA)
- continuous prophylaxis re evaluate annually (AUA 2022)
- pregnant patients repeat culture to confirm clearance (USPSTF 2019)

Setting (outpatient) monitoring:
- Symptom resolution at 48–72 h (IDSA 2010)
- Treatment failure → urine culture + alternative agent + reassess (IDSA 2010)

Follow-up plan: 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)
- Close-out criterion: follow-up + prophylaxis scheduled if recurrent

Monitoring phase: Symptom resolution by 48–72 h; if persists → culture-directed therapy; reassess for pyelonephritis if fever / flank pain develops (IDSA 2010)

Disposition

Current setting: outpatient — Empiric first-line nitrofurantoin × 5 d (or fos / TMP-SMX per local resistance) WITHOUT routine UA / culture if classic presentation in healthy non-pregnant woman; culture if pregnant / recurrent / treatment failure / atypical / male / poorly controlled DM (IDSA 2010)

Disposition criteria:
- Discharge with prescription + 48–72 h follow-up call (IDSA 2010)
- Admit only if pyelo / sepsis / pregnancy obstruction / immunocompromise (IDSA 2010)

Escalation triggers (move to higher acuity):
- Fever / flank pain → ED (pyelonephritis pivot) (IDSA 2010)
- Treatment failure at 48–72 h → culture + alternative + reassess for complicated / pyelo (IDSA 2010)
- Pregnancy + UTI → OB co-management (USPSTF 2019)
- Recurrent breakthrough on prophylaxis → urology referral (AUA 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Fever + flank pain + N/V + dysuria — pyelonephritis pathway; route OFF engine to future `uro.pyelonephritis.v1` (IDSA 2010)
- [MODERATE] Recurrent UTI (≥2 episodes / 6 mo OR ≥3 / 12 mo) — prophylaxis discussion indicated (AUA 2022)
- [MODERATE] Post-coital UTI pattern (recurrent within days of intercourse) — counsel + post-coital prophylaxis discussion (AUA 2022)

Citations

- IDSA 2011 Acute Uncomplicated Cystitis/Pyelonephritis (Gupta) + Hooton NEJM 2012 uncomplicated-UTI review + IDSA Asymptomatic Bacteriuria 2019 (Nicolle) + AUA/CUA/SUFU Recurrent UTI 2019 (Anger) + fluoroquinolone disabling-ADR / FDA safety evidence [PMID:21292654](https://pubmed.ncbi.nlm.nih.gov/21292654/)
- Cited evidence (PMID 22417256) [PMID:22417256](https://pubmed.ncbi.nlm.nih.gov/22417256/)
- Cited evidence (PMID 30895288) [PMID:30895288](https://pubmed.ncbi.nlm.nih.gov/30895288/)
- Cited evidence (PMID 31042112) [PMID:31042112](https://pubmed.ncbi.nlm.nih.gov/31042112/)
- Cited evidence (PMID 31357640) [PMID:31357640](https://pubmed.ncbi.nlm.nih.gov/31357640/)

Last reconciled with current guidelines: 2026-05-22.
References
  • IDSA 2011 Acute Uncomplicated Cystitis/Pyelonephritis (Gupta) + Hooton NEJM 2012 uncomplicated-UTI review + IDSA Asymptomatic Bacteriuria 2019 (Nicolle) + AUA/CUA/SUFU Recurrent UTI 2019 (Anger) + fluoroquinolone disabling-ADR / FDA safety evidence — PMID:21292654
  • Cited evidence (PMID 22417256) — PMID:22417256
  • Cited evidence (PMID 30895288) — PMID:30895288
  • Cited evidence (PMID 31042112) — PMID:31042112
  • Cited evidence (PMID 31357640) — PMID:31357640