Adult II Module 6: Infections and Inflammations

Emerging and Reemerging Infectious Diseases

• Primary care providers are often on the front lines of the global battle to identify, manage, and control emerging and reemerging disease

• Emerging infectious diseases result from newly discovered and previously unknown infections that threaten public health: COVID-19

• Reemerging infectious diseases are those that had formerly caused so few infections that they were no longer considered a public health threat but have recently reactivated: Polio, Zika, Dengue Fever, Ebola

• Primary care clinicians should always screen patients for any relevant travel history in order to institute appropriate infection control practices

• If suspected, expert consultation should be sought to diagnose and manage these diseases

Coronaviruses

• Coronaviruses are pathogens in animals and humans, well known as a cause of the common cold

• SARS is a coronavirus that emerged in 2002 from Guangdong Province, China

• Symptoms included severe and often fatal pneumonia

  • Fever, an influenza-like illness

  • Diarrhea, leukopenia, thrombocytopenia, and characteristically lymphopenia

  • Incubation period of 4 to 7 days

  • About 25% of patients developed severe pneumonia complicated by acute respiratory distress syndrome (ARDS)

  • Mortality was as high as 50% in older patients and hosts with underlying disease and survivors had significantly reduced exercise capacity and health status compared with the general population

Middle East Respiratory Syndrome (MERS)

• Middle East respiratory syndrome (MERS) is caused by a previously unknown coronavirus now called MERS Co-V

• All cases have been linked directly or indirectly to countries in the Arabian Peninsula, most notably Saudi Arabia, Qatar, Jordan, and the United Arab Emirates

• Incubation period of  2 to 14 days

• S/S fever, cough, and shortness of breath, gastrointestinal symptoms including diarrhea and/or nausea and vomiting

• As with SARS, most patients progress to ARDS with multi-organ system failure. The mortality rate is approximately 55%.

• Advise patients traveling to the affected region: remind strict adherence to routine measures to prevent respiratory illnesses, including washing hands, avoiding personal contact such as kissing and sharing eating utensils with ill individuals, and disinfecting frequently used surfaces such as doorknobs

Infectious Diarrhea

• Diarrhea is very common, usually self-limiting

• There are risks of morbidity and mortality related to diarrhea, especially in the very young, old, and in developing nations

• Sources usually food-borne, water-borne, or fecal/oral

Acute Infectious Diarrhea

Non-inflammatory vs. inflammatory vs. penetrating

Acute Infectious Diarrhea: Non-Inflammatory

• Noninflammatory diarrhea is caused by enterotoxin-producing organisms or by viruses that adhere to the mucosa and disrupt absorptive and/or secretory processes without causing acute inflammation or mucosal destruction

• Proximal small bowel

• Can be abrupt in onset, can be small volume (Ex: acute gastroenteritis) or large volume (Ex: cholera)

Acute Infectious Diarrhea: Inflammatory

• Inflammatory diarrhea is characterized by frequent, larger-volume, bloody stools and may be accompanied by fever, severe abdominal pain, tenesmus

• Colon

• Inflammatory diarrhea is suspected with the demonstration of leukocytes or leukocyte proteins on stool examination

• Ex: Dysentery

Acute Infectious Diarrhea: Penetrating

• Penetrating diarrhea refers to organisms that cause an inflammatory process, with eventual invasion into the bloodstream associated with systemic manifestations referred to as enteric fever

• Distal small bowel

• Ex: Salmonella typhi or typhoid fever

Travelers Diarrhea

• Likely to be non-inflammatory and of short duration

• Fecal-oral contamination of food or water is usually implicated

  • E. coli (Enteroaggregative E. coli (EAEC) and Enterotoxigenic E. coli (ETEC) are the most likely pathogens, followed by Campylobacter jejuni, Shigella species, and Salmonella species

• Prevention is the cornerstone of treatment. Traveler's diarrhea can be avoided by not drinking untreated water or ice cubes or unpasteurized milk and not eating raw fruits and vegetables and undercooked meat. Travelers should drink only sealed or carbonated beverages.

• Can occur during or up to 10 days after travel.

• Generally lasts approximately 3 to 7 days

Travelers Diarrhea Treatment

• Treatment includes oral fluid replacement, Loperamide (Imodium) 4 mg orally at onset and 2 mg after each loose stool up to 16 mg/day

• Bismuth subsalicylate (Pepto-Bismol) has both antimicrobial and anti-inflammatory effects and may be taken as 2 tablets every 30 to 60 minutes up to eight doses per day- avoid in Gout, ASA allergy, renal insufficiency

• Antimicrobial therapy:

  • Ciprofloxacin 500 mg orally twice daily for 3-5 days

  • Azithromycin 500 mg orally daily for 3 days

  • Antibiotics are typically not prescribed as a preventive measure for travelers

Vibrio Cholera

• Approximately 1.3 billion people at risk, resulting in 2.9 million cases and 95,000 deaths annually

• V. cholerae is a bacterium naturally found in water, attached to algae, crustaceans, and plankton. Warmer-than-usual waters facilitate its growth. In this activated state, humans are more likely to become infected

• Transmitted through fecally-contaminated food or water

• S/s watery diarrhea which can lead to dehydration, electrolyte imbalance, renal failure, and metabolic acidosis

Cholera Assessment

• Cholera is a potential cause of any case of severe watery diarrhea with or without vomiting, especially in patients who develop rapid and severe volume depletion

• Specifically, according to the World Health Organization, cholera should always be suspected when a patient five years or older develops severe volume depletion from acute watery diarrhea, even in an area where cholera is not known to be endemic

• Volume status should be assessed through examination of mental status, eyes, mouth, skin, and pulse

Cholera Treatment

• Fluid resuscitation

• Patients with severe volume depletion or hypovolemic shock need intravenous fluids should be urgently administered to restore circulation

• Antibiotics are an adjunctive therapy for patients with cholera and moderate to severe volume depletion. Studies have demonstrated that in such patients, effective antibiotics for cholera can shorten the duration of diarrhea, reduce the volume of stool losses, and lessen the duration of shedding of V. cholerae

• Antibiotics can be administered once the initial volume deficit is corrected and vomiting has ceased.

Clostridium Difficile

• Broad-spectrum antibiotics alter anaerobic and enteric bowel flora, allowing antibiotic-resistant C. difficile to grow and to produce antibiotic associated diarrhea and more severe pseudomembranous colitis

• Assess for recent antibiotic use, especially fluoroquinolones, clindamycin

• Treatment of C. difficile colitis is multifactorial.

  • Broad-spectrum antibiotics should be stopped if possible or changed to more narrow-spectrum agents.

  • Hydration and electrolyte replacement need to be maintained

• Oral fidaxomicin and vancomycin are preferred for initial episodes of nonsevere disease

  • Fidaxomicin (Dificid) 200 mg orally twice daily for 10 days, or

  • Vancomycin 125 mg orally 4 times a day for 10 days, or

  • Alternative: Metronidazole (Flagyl) 500 mg orally 3 times a day for 10-14 days
    
    

• Severe, complicated C. difficile colitis with ileus will not receive adequate levels of oral vancomycin to the colon. In these cases, intravenous metronidazole may result in detectable colonic levels. Rectal administration of vancomycin may also be beneficial, but should be avoided if there is concern for colonic perforation

• Fecal microbiota transplant is used quite successfully in severe cases and in immunocompromised patient. Cure rates up to 90%

• In the most severe cases, colectomy is life-saving. It should be performed in the setting of toxic megacolon, colonic perforation, and acute abdomen, and may need to be considered in septic shock.

• Fidaxomicin is an oral antibiotic that specifically targets C. difficile and has minimal impact on the intestinal flora. It has similar efficacy to vancomycin in clinical cure but lower rates of C. difficile recurrence

• Bezlotoxumab is a monoclonal antibody directed against the B toxin of C. difficile and is FDA-approved for prevention of recurrent C. difficile infection when added to standard therapy

• Antibiotic stewardship: Antibiotic use should be limited to the shortest effective course and the narrowest spectrum antibiotic for each pathogen

• Remind patients that alcohol scrubs do not inactivate C. difficile spores, so soap and water are required to remove them from hands.

Role of the Primary Care Provider: Patients Presenting with Acute Diarrhea

• Obtain a good medical history with OLDCARTS (symptom duration, frequency, and characteristics of the stool and any associated symptoms)

• Identify any epidemiologic clues

  • Recent travel, drinking untreated water, community outbreak (are there a cluster of cases?) , animal or pet contact, occupational exposure such as daycare worker, food history- ingestion of shellfish, drinking untreated water, unpasteurized milk or dairy product, raw or undercooked food (eggs, meat, fish), recent antibiotic use, new medications

• Most episodes of diarrhea in the United States are caused by noroviruses

  • self-limited, noninflammatory gastroenteritis

  • typically resolves in 2 to 3 days

  • diarrhea, nausea, vomiting, stomach pain, fever, and head and body aches

• Give antibiotics only for presentations not consistent with norovirus infection

• Consider bacterial causes if the clinical presentation is one of inflammatory diarrhea

  • fever, abdominal pain, tenesmus, large-volume diarrhea (more than six stools per day), and mucus or blood in stool

  • Order diagnostic testing while treating empirically with antibiotics

• Assess for the presence of chronic illness, chemotherapy, tube feedings, immune deficiency, or human immunodeficiency virus (HIV) infection with low CD4 counts:

  • Consider severe manifestations of norovirus, rotavirus, adenovirus, or astrovirus infection and/or atypical presentation of bacterial and parasitic diarrhea

• Chronic diarrhea lasting more than 14 days?

  • Consider protozoan parasites

• Systemic manifestations of fever, chills, rigors, night sweats, and weight loss?

  • Consider penetrating bacteria

Physical Examination: Acute Diarrhea

• Signs of dehydration (weight, temperature, orthostatic vital signs, poor poor skin turgor, dry mucous membranes, dark urine)

• Mental status

• Abdominal assessment: Carefully assess for bowel sounds, rigidity, guarding, tenderness, distention

Noninfectious Causes of Diarrhea

• Hyperthyroidism

  • In chronic diarrhea: assess for the presence of thyromegaly, tachycardia, and proptosis -> may be suggestive of hyperthyroidism

• Lymphoma or bowel cancer

  • Assess for lymphadenopathy, especially cervical node (and supraclavicular) -> may suggest lymphoma or bowel cancer

• In the female patient with lower abdominal symptoms, a pelvic examination is imperative

• In the geriatric patient, fecal impaction must be ruled out

• Consider testing for HIV infection -> diarrhea is common in HIV

Diagnostics: Acute Diarrhea

• Usually for self-limiting cases, diagnostics are not indicated

• If concern for dehydration or electrolyte imbalance: CBC, CMP

• Stool testing for bacterial pathogens: if febrile, bloody diarrhea, abdominal pain, signs of sepsis, more than six unformed stools in a 24-hour period, frail and elderly, or immunocompromised patients

• If concern for obstruction, bowel perforation: CT Abdomen/Pelvis

Patient Education/Health Promotion: Acute Diarrhea

• Good handwashing after each bowel movement reduces the possibility of spreading disease.

• Immunocompromised patients are at greater risk of severe infection and should be diligent about proper safe food handling and preparation.

• Drinking frequent, small sips of fluids (water, tea, bouillon, flat cola, flat ginger ale, or sports drink) helps to avoid dehydration.

• Avoiding foods and letting your stomach rest is advised until bowel movements begin to return to normal or until the patient begins to feel better. Gradually adding small amounts of food (e.g., crackers, toast, rice, bananas) and avoiding those that may aggravate symptoms (e.g., dairy products, caffeine, high-fat or high-fiber foods, carbonated beverages, sugar-free products, and alcohol) are helpful steps to recovery.

• It is better to avoid antidiarrheal products because most cases of diarrhea are self-limited.

Diverticulosis

• Diverticular disease is the 8^th most common outpatient diagnosis in the United States

• Outpouching of mucosa through the colon wall resulting from structural alterations, defined by the presence of numerous diverticula

• Asymptomatic diverticulosis is typically an incidental finding on imaging, found on routine colonoscopy

  • Clinical manifestations vary from diverticulosis, diverticulitis, and diverticular bleeding or hemorrhage

  • Presentation depends greatly on the severity of the inflammatory process and the presence or absence of complications

• 80% to 85% of patients will remain asymptomatic, 10% to 25% will experience diverticulitis

Diverticulosis: Pathophysiology

• Colonic diverticula are defects of the bowel wall

• They are saclike herniations of the mucosa through the muscularis propria and are actually

     pseudodiverticula because they do not contain the muscle layer)

• Exact pathogenesis of the disease is unknown but is thought to include environmental, genetic, and dietary factors

  • Occurs more often with increasing age and as diets including more refined foods (increased refined sugar/white flour, decreased fiber)

  • Low-fiber diets decrease the amount of intraluminal bulk in the colon. Lack of fecal bulk is thought to produce uncoordinated and irregular colonic peristalsis, which creates sacculations in the colon wall. This results in diverticular outpouchings at weak points.

Diverticulosis: Clinical Presentation and Physical Examination

Asymptomatic patients

• Asymptomatic diverticula are typically an incidental finding when the colon is studied for another reason with a barium enema, colonoscopy, CT scan, or ultrasound

• Do not need treatment or further follow-up

Symptomatic patients

• Signs and symptoms:

  • Intermittent abdominal pain, bloating, excessive flatulence, or irregular defecation (stool- flattened or ribbonlike to hard pellets)

  • Associated symptoms: urinary dysfunction, anorexia, nausea, vomiting, and heartburn

• Older adults: left lower quadrant steady or crampy pain, in combination with constipation or alternating diarrhea/constipation

• Physical exam:

  • Mild left-lower-quadrant tenderness with a thickened palpable sigmoid colon

  • Rectal bleeding that is bright red bleeding or maroon-colored -> may suggest a diverticular bleed

Diverticulosis: Diagnostics

Asymptomatic diverticulosis:

• Require no diagnostic workup

Symptomatic diverticulosis:

• CBC indicated if there is rectal bleeding

  • Microcytic anemia can be present in patients with chronic bleeding from diverticular disease

• Stool for occult blood

• CT scan of the abdomen/pelvis

  • Plain abdominal X-ray films will be normal and are unnecessary (can be ordered to exclude the presence of free air in the abdomen)

• After resolution of symptoms: colonoscopy, flexible sigmoidoscopy, or barium enema (x-ray of lower GI tract and colon)

Diverticulitis

• Most common complication of diverticulosis

• Severity of diverticulitis can range from mild, self-limiting uncomplicated disease to a life-threatening condition complicated by perforation, abscess, fistula, or bleeding

• Characterized by the inflammation of one or more colonic diverticula

  • Thought to result from the stagnation of fecal material in a diverticulum. This produces a fecalith, which leads to pressure necrosis of the mucosa and subsequent inflammation. As the inflammatory process progresses, perforation can occur.

Diverticulitis: Signs and Symptoms

• Mild to moderate aching left lower quadrant abdominal pain

  • Localized guarding and rigidity

  • Mild abdominal distention

• Fever

• Leukocytosis

• Nausea/vomiting (1/3 of patients)

• Change in bowel habits (constipation or loose stools)

• Rectal bleeding (uncommon)

• Diffuse abdominal pain -> indicate possible macroperforation

• Rigid board-like abdomen -> severe disease associated with peritonitis

Diverticulitis: Diagnostics

• Acute diverticulitis can be made clinically based on history and physical examination alone

• Diagnostic testing and clinical management are guided by symptom severity, signs of peritonitis, and the patient’s ability to tolerate oral intake

• CT scan of the abdomen with IV contrast is the test of choice

• Colonoscopy should be avoided in acute diverticulitis because of risk of perforation

  • Useful after the inflammatory process subsides to rule out a malignant etiology of symptoms

Diverticulitis: Pharmacologic Management (Outpatient)

• Conservative treatment with bowel rest (e.g., clear liquids and follow-up in 48 to 72 hours), increased fluid intake, and oral antibiotics to cover colonic flora.

• Oral antibiotic therapy for 7-14 days

  • amoxicillin-clavulanate (Augmentin, 875/125 mg three times daily) or

  • trimethoprim-sulfamethoxazole (Bactrim DS) 160/800 mg twice daily) plus metronidazole (500 mg three times daily) or

  • ciprofloxacin (500 mg twice daily) plus metronidazole (500 mg three times daily)

Diverticulitis: Nonpharmacologic Management

• After an episode of acute diverticulitis: low-fiber diet consisting of 15 g or less of dietary fiber to reduce the volume of fecal material in the lower bowel and to prevent irritation of the colon

  • Whole-grain breads and cereals, raw fruits and vegetables, and legumes should be avoided

• Once the patient is asymptomatic: gradual modification to a diet high in fiber

  • Do not need not avoid nuts, seeds, or popcorn

  • No relationship has been found between consumption of those foods and the development of diverticulitis

• Colonoscopy is recommended 4 to 6 weeks after symptoms resolve to exclude malignancy

Diverticulitis: Indications for Referral and Hospitalization

• Hospitalization in patients with:

  • temperature of 38.5°C (101.3°F) or higher

  • marked tenderness

  • signs of localized peritonitis, intestinal obstruction, or suspected intraabdominal or pelvic abscess

• Hospitalization is recommended for patients with diabetes or who are immunosuppressed, older adults, and patients with chronic renal failure

• Referral for surgical consultation

  • American Gastroenterological Association and American Society of Colon and Rectal Surgeons guidelines both suggest against elective colonic resection in patients with uncomplicated diverticulitis

  • In patients with complicated disease, the decision regarding surgical intervention is based on factors including the patient’s age, comorbidities, frequency and severity of attacks, and CT-graded severity of attack

Urinary Tract Infections (UTIs)

• Pathogen within the urinary system and inflammatory response

• Acute or chronic infection and/or inflammation

• Bladder (cystitis), urethra, prostate, ureter, or kidney (pyelonephritis) with microbial colonization of the urine

• UTI Types

  • Uncomplicated

  • Complicated (all UTIs in males are considered complicated)

  • Isolated

  • Unresolved-persistent infection, drug resistance

  • Reinfection

  • Relapse

UTIs: Types

• Uncomplicated: UTI in healthy, nonpregnant women with no significant history of UTIs, no underlying urologic or gynecologic abnormalities.

  • Mild to moderate symptoms

• Complicated: Associated with a condition, such as a structural or functional abnormality of the urinary tract

  • Infection may be more serious, treatment less effective

• Isolated: First occurrence; or repeat occurrence at least 6 months from the previous episode.

• Recurrent: Symptomatic UTIs that occur after resolution of a previously treated UTI

  • ≥ 2 in 6 months

  • ≥ 3 in 12 months

• Relapse: Bacterial persistence of same pathogen; not completely eradicated

• Reinfection: New bacterial strain or same bacteria after previous eradication

UTIs: Definition

• UTIs in women are secondary to ascending infection from the periurethral or perianal area

• Bacteria from the colon, vagina, or skin are the usual organisms causing the infection

• Cystitis is more common in women than in men because of the short length of the urethra and the proximity of the urethral opening and vagina to the perianal area

• Bacteria reaches the bladder through the urethra and can ascend to the kidneys through the ureters

• Precipitating factors

  • Sexual intercourse, use of spermicidal agents, a new sexual partner, maternal history of UTI, and history of UTI during childhood

  • Older women: history of UTI before menopause, urinary incontinence, atrophic vaginitis due to estrogen deficiency, cystocele, increased postvoid urine residual

  • Men: lack of circumcision, anal intercourse, HIV infection, and prostatic hypertrophy, anatomical abnormalities of the urinary tract

• UTIs are more common in young, sexually active women and older adults

• Approximately 40% of women develop a UTI in their lifetime

• Uncommon in men < 50 years of age with normal anatomy

• Most common pathogen- Escherichia coli

• Other pathogens- Staphylococcus saprophyticus and the Enterococcus, Klebsiella, Enterobacter, and Proteus genus

• Asymptomatic bacteriuria (ABU)

  • Significant levels of bacteriuria (colony count >100K) without symptoms

  • Risk factors- pregnancy, history of indwelling catheterization, instrumentation, urinary incontinence, diabetes, medical illnesses, obstructive uropathy, postmenopausal status, impaired functional and mental status

• Risk factors- decreased fluid intake, irregular bladder emptying, comorbidities- diabetes, etc

UTIs: Clinical Presentation

• Symptoms vary based on the type of UTI

• Screen and assess for

  • Urinary frequency, nocturia, dysuria, pruritus, fever or chills, hematuria, vaginal discomfort or discharge, pelvic discomfort, back or flank pain, date of last menstrual period, any prior history of UTIs, cervicitis, or pelvic inflammatory disease (PID), dyspareunia

• Male- urethral discharge, penile lesions, history of UTIs, STIs, and prior treatment

• Acute UTIs include symptoms of

  • Increased frequency, urgency, dysuria, suprapubic pain, odorous urine, and occasionally hematuria

• Complicated UTI symptoms include

  • High fever, chills, flank pain, costovertebral angle tenderness, nausea, and vomiting, pyuria (pyelonephritis)

UTIs: Physical Exam

• Vital signs

• Thorough abdominal exam, pelvic, periurethral and perianal exam, penile, prostate

• Females

  • Assess: vulva, vagina, cervix, periurethral and perianal areas for discharge, excoriations, tenderness, and ulcerations.

• Males:

  • Assess penis for discharge, lesions, ulcerations, and swelling

  • Assess prostate for tenderness, swelling, masses, or nodules.

  • DRE: tender prostate may be indicative of acute prostatitis

  • normal or enlarged prostate can indicate chronic bacterial prostatitis

UTIs: Diagnostics

• Urinalysis

  • Clean-voided midstream specimen

  • Nitrates, leukocyte esterase, bacteria, WBCs, RBCs, and blood in the urine are (+) signs of infection

• Urine culture is the definitive test

• Urine cultures should be obtained from patients with the following:

  • History of frequent UTIs

  • Empirical treatment failed

  • Febrile or seriously ill

  • Live in a community with high rates of antibiotic resistance,

  • Recently been hospitalized

  • Pregnant women

  • Young men (UTIs are unusual and may suggest underlying problems)

• Sterile pyuria- negative urine culture despite a positive urinalysis, e.g. positive leukocyte esterase, WBCs)

• Multiple bacterial species identified by culture- suggest contamination of the specimen unless catheterized specimen

• Large numbers of skin flora, such as Staphylococcus epidermidis, diphtheroids, and β-hemolytic streptococci, can usually be ignored.

• Candida organisms usually suggest vaginal contamination.

• Beta strep should not be ignored in pregnancy

• Test of cure urine culture should be obtained in men and whenever there is suspicion that an infection may not have been eradicated

  • Routine testing of cure cultures is not indicated unless a persistent UTI is suspected

• Renal ultrasounds- structural abnormalities, calculi, masses, and hydronephrosis

UTIs: Management in Nonpregnant Adults

Empiric antimicrobial management in the outpatient setting

Acute simple cystitis in nonpregnant adults

• First-line therapy

  • Nitrofurantoin (Macrobid) 100mg orally twice daily (5 days for females, 7 days for males)

  • Trimethoprim-sulfamethoxazole (Bactrim) 160/800mg orally twice daily (3 days for females, 7 days for males)

  • Fosfomycin 3g orally single dose for 1 day

• Beta-Lactam Alternatives:

  • Amoxicillin-clavulanate 500 mg orally twice daily (5-7 days for females; 7 days for males)

  • Cephalexin 500 mg orally twice daily (5-7 days for females; 7 days for males)

• Fluoroquinolone Alternatives: useful for males concerned with prostatitis

  • Ciprofloxacin 250mg orally twice daily (3 days for females, 5 days for males)

  • Levofloxacin 250mg orally once daily (3 days for females, 5 days for males)

• Phenazopyridine (Pyridium)- urinary analgesic

• Prophylaxis: initiated when the existing UTI has been eradicated, confirmed with negative culture 1 to 2 weeks after treatment

• Topical estrogen cream- symptomatic relief in postmenopausal women

• Chronic/recurrent UTIs

  • Refer to urology consult

UTIs: Complications

Pyelonephritis

• Most common

• Bacterial infection of the kidney resulting from ascending, untreated, or inadequately treated lower UTI

  • Uncomplicated pyelonephritis- can be treated outpatient

  • Complicated- inpatient management

  • 
    

Urosepsis

• Life-threatening systemic complication

  • requires hospitalization with high-dose parenteral antimicrobial therapy, IV volume repletion, etc

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Rare complications

• Emphysematous cystitis

• Abscess formation

• Renal papillary necrosis

UTIs: Referral

• Presence of macroscopic hematuria, suspected malignancy, recurrent UTIs or infections that do not respond to standard antimicrobial therapy

• Urinary tract anomalies or obstructions, acute scrotum, and all forms of prostatitis. Hospitalization is recommended for pregnant women with pyelonephritis.

• Older adults and those with acute, severe symptoms are candidates for hospitalization and often require parenteral therapy

• Comorbidities -diabetes mellitus, sickle cell anemia, nephrolithiasis, 

• Excessive analgesic use increase risk of renal papillary necrosis and obstruction

UTIs: Patient Education

• Void 10 to 15 minutes after sexual intercourse

• Adequate fluid intake (64 to 80 ounces daily)

• Regular urination(at least every 4 hours)

• Wiping from front to back, tampons use during menstruation

• Avoiding wiping more than once with the same tissue, extended soaking in a bathtub, wearing tight-fitting underwear made of nonbreathable fabric

• Avoid spermicidal products

• Seek treatment as soon as symptoms are recognized if previous hx UTI

• Educate about the possible benefits of antimicrobial suppression or postcoital prophylaxis

• Intravaginal estrogen cream for postmenopausal women with recurrent UTIs