Test & Treat Services

TEST AND TREAT PROTOCOL: Acute Uncomplicated Lower Urinary Tract Infection, Women (18-64)

Note: this is patient variation #3.

First Name:	Last Name:
Date of Birth (MM/DD/YYYY):	Age:	Gender:
Telephone:	Email:
Address:	City:
State:	Zip Code:
Primary Healthcare Provider:
Medication Allergies:
Current Medications:
Treatments tried for current condition:

Physical Assessment (please record values)	Refer to PCP if determined clinically unstable in pharmacist professional judgment or any of the following criteria
Blood Pressure Systolic: mmHg Diastolic: mmHg	Systolic blood pressure < 90 mmHg or Diastolic blood pressure < 60 mmHg
Respiratory Rate: bpm	Respiratory rate > 30 breaths/min (single criteria); Respiratory rate > 20 breaths/min (dual criteria)
Oxygen Saturation: %	Oxygen saturation (SpO2) < 90% via pulse oximetry
Pulse: bpm	Pulse > 125 beats/min (single criteria); Pulse > 90 beats/min (dual criteria)
Temperature: °F	> 103 °F (oral), or > 102 °F (temporal), or > 104 °F (tympanic) (single criteria); < 96.8 °F (single criteria); > 100.4 °F (dual criteria, or pyelonephritis possibility in combination with nausea/vomiting or flank pain)
Acute altered mental status Yes No	Yes

	Nitrite	WBC

Clinistix® UTI Urine Test Strips (Siemens, Lot# 472307, Exp Date: 2/26/2028)

Positive urine dipstick for nitrites and/or leukocytes indicating UTI

Negative for UTI

POC Test Manufacturer:

POC Test Lot#:

POC Test Exp Date:

UTI Diagnosed: Yes No

Antibiotic Treatment Prescribed: Yes No

Refer to PCP: Yes No

Acute Uncomplicated UTI Treatment
Instructions: the choice between the antibiotic medication regimens should be individualized and based on patient allergy, contraindications/precautions, adherence history, local community resistance patterns, cost, and availability. Antibiotic Treatment Nitrofurantoin monohydrate/macrocrystals Dosing: 100 mg PO BID for 5 days Trimethoprim-sulfamethoxazole Dosing: 160/800 mg PO BID for 3 days Fosfomycin trometamol Dosing: 3 gm PO single dose This Protocol also authorizes pharmacists to initiate the dispensing of the following medication for the treatment of UTI related dysuria: Phenazopyridine 100-200 mg PO three times daily (TID) after meals for up to 2 days when used concomitantly with an antibiotic agent.
Documentation of rationale for treatment selection:

Nitrofurantoin monohydrate/macrocrystals	Dispense: 100 mg, #10, no refills	Dosing: i po BID for 5 days
Trimethoprim-sulfamethoxazole	Dispense: 160/800 mg, #6, no refills	Sig: i po BID for 3 days
Fosfomycin trometamol	Dispense: 3 g, #1, no refills	Sig: i po as a single dose

Yes	No	Are you 18-64 years of age?
Yes	No	Do you have a history of urinary tract infections?
Yes	No	Are you pregnant or breastfeeding?
Yes	No	Are you pre-menopausal?
Yes	No	Are you diabetic?
Yes	No	Have you ever been diagnosed with a weakened immune system (e.g., cancer, HIV/AIDS, transplant, long-term steroids, etc.)?
Yes	No	Have you ever been diagnosed with c.diff (Clostridioides difficile, formerly Clostridium difficile)?
Yes	No	Do you have a history of renal transplant, dysfunction, urologic surgery (ureteral implantation, cystectomy, urinary diversion), or abnormal urinary tract function or structure (indwelling catheter, chronic intermittent catheterization, neurogenic bladder, renal stones, renal stents)?
Yes	No	Do you have a history of allergic reactions to antibiotics, such as penicillin, amoxicillin, cephalexin, clarithromycin, or clindamycin?
Yes	No	Are you a resident of a nursing home or long-term care facility, in hospice, or receiving home health services?
Yes	No	Do you have a pending test for your symptoms?
Yes	No	Have you been prescribed antibiotics in the previous 30 days?
Yes	No	Have you had an inpatient or hospital stay in the previous 30 days?
> 7 days ago	< 7 days ago	When did your symptoms start?
Pain when urinating:	Flank pain:	Do you have any of the following symptoms (indicate all that apply)?
Increased urinary frequency/urgency:	Vaginal discharge or itching:
Nausea/vomiting	Other