Is the care plan and note appropriate for a 45‑year‑old female with a 2‑day history of uncomplicated cystitis (mild dysuria, polyuria, no fever, no costovertebral angle tenderness), who declined urinalysis and sexually transmitted infection testing, per Infectious Disease Management Team protocols?

Assessment of Care Plan and Documentation for Uncomplicated Cystitis

This care plan contains significant gaps that compromise patient safety and deviate from evidence-based standards, particularly the failure to obtain urinalysis before empiric treatment and inadequate documentation of antibiotic selection.

Critical Deficiencies in the Current Approach

Diagnostic Testing Omission

• The patient declined urinalysis, yet empiric antibiotic treatment was initiated—this approach contradicts current guidelines that emphasize the importance of confirming pyuria before treatment, especially when the diagnosis relies solely on history. 1

• While diagnosis of uncomplicated cystitis can be made with high probability based on focused history of lower urinary tract symptoms (dysuria, frequency, urgency) and absence of vaginal discharge, when patients present with typical symptoms, dipstick analysis increases diagnostic accuracy and helps distinguish true infection from other causes of dysuria. 1

• The 2024 European Association of Urology guidelines state that urine culture is recommended when symptoms do not resolve or recur within 4 weeks after completion of treatment, or when women present with atypical symptoms—this patient's refusal of initial testing may complicate future management if treatment fails. 1

Missing Critical Documentation Elements

The note fails to document which specific antibiotic was prescribed, the dose, duration, or the rationale for selection—this represents a fundamental documentation failure that prevents quality review and continuity of care. 1

• First-line empiric treatment options for uncomplicated cystitis include: nitrofurantoin 100 mg orally twice daily for 5-7 days (preferred due to minimal resistance rates), fosfomycin trometamol 3 grams as a single oral dose, or trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days only if local E. coli resistance is <20%. 1, 2

• The choice of antimicrobial therapy should be guided by spectrum and susceptibility patterns of aetiological pathogens, efficacy in clinical studies, tolerability, adverse ecological effects, and costs/availability—none of these considerations are documented. 1

Inadequate Safety Net and Follow-Up Instructions

• The instruction to "F/U with PCM if condition does not improve" is too vague. Guidelines specify that women whose symptoms do not resolve by the end of treatment, and those whose symptoms resolve but recur within 2 weeks, require urine culture and antimicrobial susceptibility testing. 1

• The threshold for emergency department referral (fever of 100.4°F) is too low—guidelines define fever as >38°C (100.4°F is 38°C exactly), but uncomplicated pyelonephritis typically presents with fever >38°C, chills, flank pain, nausea, vomiting, or CVA tenderness. 1

• The note should specify return precautions for: symptoms not resolving within 48-72 hours, development of fever >38.3°C, flank pain or CVA tenderness, nausea/vomiting, or gross hematuria. 1

Appropriate Elements of the Current Note

• The history adequately documents absence of upper tract infection symptoms (no CVA tenderness, fevers, chills) and absence of complicating factors (no concerns for STIs, no abdominal pain), which supports classification as uncomplicated cystitis. 1

• The physical examination appropriately assessed for CVA tenderness and abdominal findings to exclude pyelonephritis and other complications. 1

• Documentation that the patient has had prior UTIs with similar symptoms supports the clinical diagnosis, as self-diagnosis of UTI with typical symptoms has >90% accuracy in women. 3

Recommendations for Improved Practice

Mandatory Documentation Elements

Every UTI treatment note must include:

• Specific antibiotic prescribed (generic and brand name)
• Exact dose and frequency
• Total duration of therapy
• Rationale for antibiotic selection (first-line agent, allergy considerations, prior culture results)
• Patient counseling regarding completion of full course
• Specific return precautions with quantified thresholds 1, 3

Handling Patient Refusal of Testing

When a patient declines urinalysis in suspected uncomplicated cystitis:

• Document the refusal explicitly and that risks/benefits were explained
• Explain that without urinalysis, you cannot confirm pyuria (≥10 WBCs/HPF or positive leukocyte esterase), which is required to distinguish true infection from other causes of dysuria 4
• Inform the patient that 10-50% of culture-proven UTIs may have false-negative urinalysis, but the absence of pyuria effectively rules out UTI with 82-91% negative predictive value 4
• Consider symptomatic therapy with NSAIDs as an alternative to empiric antibiotics for mild-to-moderate symptoms, as guidelines state that ibuprofen may be considered in consultation with individual patients 1
• If proceeding with empiric treatment despite refusal, document that treatment is based on clinical probability alone and that culture will be mandatory if symptoms fail to resolve 1, 3

STI Screening Considerations

• The patient declined STI testing, but the note should document whether risk factors for STI were assessed—dysuria with vaginal discharge suggests cervicitis/urethritis rather than cystitis. 1

• In women with dysuria and risk factors for STI (new sexual partner, multiple partners, partner with STI), urethritis from Chlamydia trachomatis or Neisseria gonorrhoeae must be excluded before attributing symptoms to UTI. 1

Quality Improvement Considerations

This case highlights the tension between patient autonomy (declining testing) and evidence-based care—the optimal approach is shared decision-making where the clinician explains that:

• Urinalysis takes 2-3 minutes and provides objective confirmation of infection 4
• Without testing, there is 15-50% probability of treating asymptomatic bacteriuria or non-infectious causes of dysuria, leading to unnecessary antibiotic exposure and resistance 4
• If symptoms do not improve, delayed testing will be mandatory and may require a second visit 1

The note should reflect this counseling and the patient's informed decision to proceed without testing, rather than simply stating "member declined UA."