Cystitis

Are you female at birth aged between 18 – 64 years old? *

Are you currently pregnant or possibly pregnant or breast-feeding? *

Are you using urinary catheter devices including indwelling urethral catheters, supra-pubic catheters or intermittent self-catheterisation? *

Have you had recurrent UTI? *

• Two episodes in the last 6 months or
• Three episodes in the last 12 months

Are you having any urinary signs and symptoms? (Tick if applies to you) *

Are you showing any other symptoms or signs of deterioration? *

Have you had unprotected sex recently that you are concerned might have exposed you to a sexually transmitted disease? *

Are you currently experiencing menopause or post-menopausal symptoms? *

For example:

• Vaginal Dryness
• Burning or irritation of vagina
• Vaginal Itching
• Discomfort or pain during sex (dyspareunia)
• Bleeding or spotting after sex

Have you taken any antibiotic for a UTI in the past 3 months? *

Have you had a failed previous antibiotics for this episode of UTI? *

Are you taking any prophylactic antibiotics for UTI? *

Have you ever been told your cystitis infection is resistant to an antibiotic? *

Do you have any of the following conditions? *

• G6PD deficiency
• Acute Porphyria
• Anaemia
• Diabetes Mellitus (Type 1 or 2)
• Folate deficiency
• Vitamin B deficiency
• Peripheral neuropathy
• Electrolyte imbalance
• Blood disorders
• Severe liver problems
• Hereditary galactose intolerance, Lapp lactase deficiency, or glucose-galactose malabsorption
• Raised Potassium level (Hyperkalaemia)

Are you taking the following: *

• Receiving 14 days before, and for 10 days after live cholera vaccines
• Less than 3 days before receiving, or within in 3 days after receiving oral Typhoid vaccine
• Folate antagonists, used to treat folate deficiency (e.g. aminopterin or methotrexate)
• Bone Marrow depressants (e.g. azathioprine, cytarabine, or daunorubicin)
• Repaglinide, used to treat diabetes
• Procainamide, to treat abnormal heart rhythm
• Digoxin, to treat heart conditions
• Diuretics (e.g. water tablets such as eplerenone, spironolactone, amiloride or triamterene)
• Rifampicin, used to treat TB
• Anticoagulants (to prevent clots from forming in the blood e.g. warfarin)
• Phenytoin to treat epilepsy
• Pyrimethamine and dapsone, used to treat malaria
• Immunosuppressant drugs – used in cancer treatment (e.g. methotrexate) or to treat organ rejection after transplant (e.g. azathioprine or ciclosporin).
• Potassium supplements
• Medicines known as ACE inhibitors and angiotensin II antagonists (used to treat high blood pressure and certain heart conditions).
• Heparin (used to treat and prevent blood clots)

Are you with primary or acquired immunodeficiency or taking any medications that suppress your immune system? *

Do you have any kidney problems or have you been told you have reduced kidney function? *

Do you have any allergies? Have you ever had an allergic reaction or adverse response to Nitrofurantoin or Trimethoprim? *

I understand I should wait 2 days for cystitis to resolve on its own before resorting to using antibiotics. This is to avoid the over-use of antibiotics resulting in antibiotic resistance *

I understand there are self-care measures for symptom relief *

• Use of short-term over-the-counter simple analgesia such as paracetamol or ibuprofen, depending on any contraindications
• Maintain adequate hydration and aim to drink 1.5 L of water a day if there are no contraindications.

I understand medicines which make the urine less acidic such as over-the-counter cystitis preparations containing potassium citrate, sodium bicarbonate or sodium citrate decreases the antibacterial action of nitrofurantoin and should not be taken during the course of nitrofurantoin. *

I understand to seek urgent medical attention if symptoms worsen rapidly or significantly at any time or do not improve within 48 hours of starting antibiotic treatment. *

I understand blood in the urine could be a sign of UTI but I would seek medical attention if this continues after treatment with antibiotics. *

I understand I would talk to my doctor if I experience trouble breathing, shortness of breath, a lingering cough, coughing up blood or mucus, or pain or discomfort when breathing. *

I understand urine may become discoloured (brown/yellow) while taking nitrofurantoin but that this is not of concern and urine will return to normal colour when the course is complete *

I understand the following would help to reduce the risk of UTI in the future: *

• Wipe from front (vagina) to back (bottom) after using the toilet
• Pass urine as soon as I need.
• Go for a wee after having sex to flush out any bacteria that may be near the opening to the urethra
• Wash the external vagina area with water before and after sex to wash away any bacteria that may be near the opening to the urethra

I understand antacids such as magnesium trisilicate can decrease the absorption of nitrofurantoin and should not be taken during the course of nitrofurantoin. *

I understand I should complete the full course even if symptoms improve. *

I will seek medical advice from my GP or 111 if my symptoms return on finishing a course of antibiotic *

Can we share this information with your General practitioner? Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to contact your regular prescriber if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records *

To ensure your medication is prescribed safely, our clinical team may need to: *

• Access your medical records (including your Summary Care Record, where applicable)
• Invite you to take part in a follow-up phone or video consultation for further clarification
• By submitting your responses, you consent to this where clinically appropriate, and agree to upload a summary health record from your prescriber or pharmacist if required.

Do you agree to the following? *

• The information I have provided is true and accurate to the best of my knowledge.
• The information I have provided will be used to determine if it is appropriate to supply medication.

Do you agree to the following terms? *

• You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health
• You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable
• You will inform your doctor about any unusual side effects
• The treatment is solely for your own use
• You will read the patient information leaflet supplied with your medication
• You will not exceed the maximum daily dose of this medication
• You confirm you have the capacity to make decisions about my own health