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Acute Uncomplicated Cystitis Screening and Treatment - Adult - Ambulaory [94]

Acute Uncomplicated Cystitis Screening and Treatment - Adult - Ambulaory [94] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 94

Delegation Protocol Title:
Acute Uncomplicated Cystitis Screening and Treatment - Adult - Ambulatory

Delegation Protocol Applies to:
Primary Care Clinics, Urgent Care, Obstetrics and Gynecology

Target Patient Population:
Adult female patients with symptoms indicative of uncomplicated acute cystitis (urinary tract
infections, UTI)

Delegation Protocol Champions:
Michelle Bryan, MD - Department of Family Medicine, General
Steven Tyska, MD – Department of Family Medicine, Urgent Care
Laurel Romer, MD – Department of Internal Medicine

Delegation Protocol Reviewers:
Cheryl DeVault, BSN, RN, OCN – Clinic Operations Manager – Yahara Clinic
Kelly Case, RN – Family Medicine – Yahara Clinic
Linda Kiefer, RN – Clinical Supervisor – Deforest Windsor
Elizabeth Kolk, RN, MBA – UWHC Internal Medicine – Women’s Health
Ronnie Peterson, RN, MS – UWMF – UW Healthline
Lucas Schulz, PharmD, BCPS, AQ-ID - Infectious Diseases Clinical Coordinator
Andrea Stumpf Guerrero, RN – Family Medicine, Urgent Care

Responsible Departments:
Department of Family Medicine
Department of Medicine
Department of Obstetrics and Gynecology

Purpose Statement:
This delegation protocol delegates authority from ordering providers to Registered Nurses (RNs)
in UW Health clinics to screen for and treat uncomplicated acute cystitis in women.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RN) trained in the use of this delegation protocol.

Guidelines for Implementation:
1. The protocol is initiated when a non-pregnant female patient 18 years or older contacts the
clinic with symptoms indicating possible acute cystitis, including dysuria, frequent urination
or urgent urination, hematuria.
1.1. Exclusions to this protocol are age less than 18 years, male sex, pregnancy or the
presence of an indwelling catheter. If the patient is excluded from the protocol, the RN
will consult the provider before placing any orders for additional direction.
1.2. If the patient reports vaginitis or risk factors for sexually transmitted infections (STI)
including recent change in vaginal discharge or odor, new pain with intercourse,
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

contact with partner infected with STI, new partner in last 3 months and condom not
used in addition to UTI symptoms, the RN will consult the provider before placing any
orders for additional direction.
2. The RN will conduct a patient assessment using the scripted assessment text contained in
the OP – Cystitis RN Delegation Protocol Smart Set. The RN will use the responses to the
interview questions in combination with a chart review including medications, allergies,
problem list and past medical history to determine the appropriate action.
2.1. If the patient has any complicating factors listed below, the RN will enter orders for
urinalysis with microscopy and culture if >5WBC/HPF and the provider will be consulted
for additional direction. Complicating factors include:
2.1.1. First episode of cystitis symptoms
2.1.2. Urologic structural or functional abnormality including indwelling catheter
2.1.3. Nephrolithiasis
2.1.4. Recurrent cystitis, i.e., four or more episodes in the past 12 months
2.1.5. Failure of antibiotic therapy for cystitis in the last month
2.1.6. Duration of symptoms greater than 7 days
2.1.7. Immunosuppressed; large doses of steroids (prednisone > 10 mg/day;
dexamethasone > 1.5 mg/day), immunomodulators [for example, adalimumab
(Humira), etanercept (Enbrel), tacrolimus (Prograf)] or chemotherapy
2.1.8. Urinary tract procedure or catheterization in last 2 weeks
2.1.9. Pyelonephritis in past 3 months
2.1.10. Discharge from hospital or nursing home in last 2 weeks
2.2. If the patient has any features consistent with possible pyelonephritis, the RN will
schedule an office visit with a provider and enter an order for urinalysis with
microscopy and culture if >5WBC/HPF (HCUACULT). If no office visits are available, the
patient will be directed to Urgent Care. Features consistent with possible
pyelonephritis include:
2.2.1. Fever > 101 F
2.2.2. Rigors
2.2.3. Unilateral flank pain
2.2.4. Inability to tolerate oral medications, nausea or vomiting
2.3. If the patient does not have any complicating factors (e.g. possible pyelonephritis,
vaginitis, or risk factors for STD’s), the RN will order one of the following antibiotic
regimens based the patient’s allergy profile and renal function.
3. Antibiotic Therapy
3.1. The RN will prescribe the first antibiotic in the list unless the patient has any
allergies/contraindications or has had a treatment failure in the past 3 months on this
antibiotic. In that case the RN will move to subsequent antibiotics. If the patient has
allergies/contraindications or has had a treatment failure to all of the listed antibiotics
they will consult a provider before placing any orders.
3.2. The allowed antibiotic regimens are listed below in order of preference. Nitrofurantoin
macrocrystals is the agent of choice.
3.2.1. Nitrofurantoin macrocrystals 100 mg by mouth twice daily for 5 days (if GFR < 60
may not prescribe by protocol).
3.2.2. Trimethoprim/sulfamethoxazole DS (TMP/SMZ), 160 mg/800 mg by mouth twice
daily for three days (contraindicated if patient on Warfarin)

Order Mode:
Medications: Protocol/Policy Without Cosign
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Laboratory: Cosign Required, Protocol/Policy

References:
1. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the
treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by
the Infectious Diseases Society of America and the European Society for Microbiology and
Infectious Diseases. Clin Infect Dis 2011 Mar; 52(5): e103-e120.
2. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 91:
Treatment of urinary tract infections in nonpregnant women. Obstet Gynecol 2008 Mar;
111(3): 785-794.
3. University of Wisconsin Hospital and Clinics. Antimicrobial Use Guidelines July 2011-2012.
21
st
edition. . Accessed March 2, 2012.
4. Hooton TM. Uncomplicated Urinary Tract Infection. N Eng J Med 2012 Mar; 366(11): 1028-
37.
5. University of Wisconsin Hospital and Clinics. Treatment of Infections of the Urinary Tract in
Adult Patients Inpatient/Ambulatory/Primary Care/Specialty Care/Home Health – Clinical
Practice Guideline. https://uconnect.wisc.edu/clinical/cckm-
tools/content/?path=/content/cpg/infection-and-isolation/name-97539-en.cckm. Accessed
September 19, 2016.
6. Briggs, Julie K. Telephone Triage Protocols for Nurses. Fourth Edition. Providence Health &
Services, Portland, Oregon.


Collateral Documents:
OP – Cystitis Delegation Protocol – Adult [5187]

Approved By:
UW Health Ambulatory Protocol Committee – July 2013, June 2016 (expedited review)
UWHC Antimicrobial Use Subcommittee – August 2013, June 2016 (expedited review)
UWHC Pharmacy and Therapeutics Committee – December 2013, June 2016 (expedited review)
UWHC Medical Board – January 2013, June 2016 (expedited review)
UW Health Chief Medical Officer – February 2014, June 2016 (expedited review)

Effective Date: June 2016

Scheduled for Review: June 2019

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org