Understanding repeat E.coli related cystitis, bladder infections, and UTIs

Clearly, there must be a first time for such contamination and infection, but in the vast majority of cases, (though not all) apparently repeat infections are the result of E.coli that survived the previous infection, and have been dormant in the bladder [Proof!] until stimulated into releasing pods from their colony to once again multiply out of control. E.coli are uniquely adapted super mutators.

E.coli survive antibiotic attack

There is good evidence for this, although not many doctors appear to have taken it on board yet (from the number of women who tell us that their doctor keeps lecturing them on personal hygiene.)

When you actually sit down and think about the pattern of most repeat infections, logic leads you to the same conclusions. Darwin'sSurvival of the Species through Natural Selection explains the process through higher forms of life, and E.coli survives as a life form in the same way that we have evolved as humans - by survival of the fittest.

Every medical practitioner and every cystitis sufferer knows that E.coli become increasingly resistant to antibiotics used against them. It is important for the understanding of how antibiotic resistance takes place to realise that it's not your body that builds up a resistance to antibiotics, it is the infection agent - in the case of bladder infections, usually E.coli.

Top

Here is how that works:

Asexual Survival Characteristics (E.coli)

If you kill all of x with an antibiotic, then there are no x survivors, and if you were to again be infected with x (as a fresh contamination), and took the same antibiotic, there could be no increase in the resistance of x. It would be just like the first time, and they would be all killed.

But this is where natural selection comes in. E.coli are asexual organisms with natural variation in the genetic makup of some of the bacteria in every colony. In effect E.coli are genetic clones of each other, but there are occasional mutations that produce genetic variation, giving the variation different survival capabilities. For example, although some of the mutations will have poor survival capabilities, some E.coli in every colony may be able to survive unusual heat, cold, toxin levels, antibiotic attack, or high acidity or alkalinity. They pass on these survival characteristics to their progeny.

Doctors attempt to fight the resistance of E.coli by varying the antibiotics used, and by increasing antibiotic dose levels to compensate for the resistance effect, but this only exasperates the problem as the E.coli become increasingly resistant, even to broad-spectrum antibiotics. The result is seriously resistant E.coli that only something that defeats the E.coli in another way (like Waterfall D-Mannose) can get rid of from your body.

Top

Variant E.coli and Antibiotic Resistance

The mechanism of E.coli antibiotic resistance is that one or more natural E.coli variants, (lets call it variant xy), survives the antibiotic attack. For example, by not succumbing to fluorine poisoning. So the antibiotic kills off all x colonies, and xy is left to multiply and establish colonies of it's own, passing on its resistance to fluorine (or whatever toxin the antibiotic utilised) to its duplicates. Most of the xy colonies will be xy type variant, and we already know that xy variant can survive the antibiotic that killed all its x brothers. It's a born survivor. You can't use what you used to kill x, to kill xy - at least not at the same dose levels or not for the same treatment length. So you'll need a longer course of antibiotics or at a stronger dose level to kill xy. And don't forget, xy will have its own variants. Somewhere, there will be an xz variant that can survive these bigger doses.

Lets look at the logic again: We know for a fact that E.coli builds up resistance to any antibiotic used against it. It can only do that if some of the bacteria survive the antibiotic attack. If your second episode of cystitis is simply a fresh contamination of the same E.coli that you were previously contaminated with, we are not talking about mutated survivors of the antibiotic, we are talking about the plain old original bug again, so the same dose level of the same antibiotic will work as well as it did before. However, that is not how the course of repeated cystitis attacks works. Typically, infection becomes more and more frequent. Patients go back for more antibiotics. Doctors find that the same dose level doesn't work, so they increase the dose levels, and increase the number treatment days. Or they vary the antibiotic. Gradually, they have to move on to big hitting fluorotoxins like Ciprofloxacin. See Business Week Cipro: Now for the Downside

Thus, increasing resistance could not happen if the cystitis were the result of fresh E.coli contamination of non-resistant bugs through faecal contamination or introduced through a sexual partner, or by any other route. Resistance occurs because of survival of the fittest - survival from a previous contamination.

Logic therefore tells us that resistant E.coli is left in the bladder after treatment with antibiotics. Fact tells us that it's detectable six weeks later in 35% of women. A year later it has recurred in half of all antibiotic treated women.

Implications and Avoidance

From the fact that if you are suffering from repeat episodes of cystitis, E.coli are probably living in your bladder, dormant or not, it is apparent that it is more difficult to avoid than it would be if the problem were simply cross-infection, or poor hygiene. And anyway, once you've had an episode or two of cystitis you'll be obsessively clean. What we've found is that there can be a number of triggers that lead to the next episode - a number of triggers that lead to the reactivation of dormant E.coli already in the bladder, or the release of E.coli pods from behind biofilms in the bladder (the biofilms are made of the same stuff as your bladder wall.)

The triggers for dormant E.coli release and causes of fresh contamination also differ, although there is some crossover. Whatever caused that very first infection, it is what makes new or apparently new that is important to sufferers.

Triggers for dormant E.coli release:

Previous history of infection and antibiotic use. The more recent the use of antibiotics, the greater the probability that an infection is caused by dormant E.coli being released.
Dehydration (allows high concentration of uric acid. E.coli seems able to sense when conditions are right for multiplication. It thrives in an acid environment, and even releases its own acid.) Beware of drinking too much coffee or alcohol. If you have a dry mouth, you are probably dehydrated.
Acidic urine through drinking acidifying drinks like orange juice or cranberry. Cranberry tablets have the same effect. (Although they contain a small amount of D-Mannose, this is not enough to stop infections. The acidifying effect just makes E.coli infections worse, although cranberry can be useful for Proteous infections.)
Sexual intercourse or other stimulation of the bladder, such as by vigorous exercise. This can even trigger long-dormant E.coli pods to begin releasing E.coli into the bladder, for example, even if you have not had sex for ten years, you can get 'honeymoon cystitis' when you next have sex.
Various spices with properties that allow them to get into the urine and act as an irritant.

Top

Antibiotic dose levels

With dormant E.coli release, taking the same level of antibiotic over the same period as your previous infection is unlikely to clear the problem, and will make the infection more resistant through the process of natural selection. Taking a higher or longer dose of antibiotics is likely to clear the current episode of cystitis, but produce more resistant dormant E.coli, making your next episode even harder to clear.

Top

Causes of fresh or first contamination:

Insufficient cleaning after toileting (the old wipe from front to back thing...)
Unhygienic sexual intercourse. Make sure you are both clean.
Oral sex. The mouth and nose harbours E.coli amongst many other bugs. Kissing your partner before he performs cunnilingus can lead to your own mouth bacteria getting up your urethra.
Catheterisation. Even exposure to the air for a few seconds with a fresh catheter is enough to contaminate it.
Internal examinations. Bacteria are everywhere, so that speculum that's been kindly warmed up on a radiator is probably not a good idea. And anyway, E.coli can survive boiling, (and those that do are really tough little guys) so is the speculum really clean in the first place?

If you are actually suffering from bacterial infection, and not from a blockage or gynocological problem, it should be possible from the above to understand what is causing repeat bladder infections or UTI's, and that is a good place to start fighting them.

Top

Recognising Interstitial Cystitis

This is a huge subject area, which we can only touch on lightly here.

A huge number of bladder problems, ranging from painless but frequent urination through to severely crippling and debilitating bladder pain that gets worse as the bladder gets full, are labelled under the general heading of 'interstitial cystitis'.

Other possible causes of the symptoms found in IC include physical abnormalities such as prolapse of the bladder, vaginal infections, urinary tract infections or disorders, endometriosis, bladder cancer, sexually transmitted diseases, and kidney stones. Tests may be necessary to rule out these causes.

When blockages, physical abnormalities, and symptom-causing diseases are ruled out, the absence of infection, when combined with pain or frequent urination, is the over-riding factor that can lead to a diagnosis of interstitial cystitis.

Some level of incontinence.
Women's symptoms often get worse during their periods.
Pain during sex.
Irritation of bladder lining may be apparent when viewed through camera.
Pinpoint bleeding in the bladder.
Blood or pus in urine, with or without pain.
Microscopic examination of 'spots' in bladder wall may reveal fragments of dead bacteria.
Small ulcers (Hunner’s ulcers ) covering entire inside of bladder or isolated areas.
Raised histamine levels may indicate that some allergic reaction is taking place.
Dormant E.coli colonies surviving inside lining of bladder.

Top

Triggers for Interstitial Cystitis (IC)

Some people believe that certain foods such as tomatoes, spices, alcohol, chocolate, caffeinated and citrus beverages, and high-acid foods may add to bladder irritation and inflammation. Others notice that their symptoms get worse after eating or drinking products containing artificial sweeteners. If you believe that your interstitial cystitis is related to your diet, try keeping a diary of food and symptoms. Or try cutting out all of the above, and gradually introducing them to see what is the trigger.

Unfortunately, the triggers are not always detectable. Interstitial cystitis can affect otherwise healthy individuals for no apparent reason. However, it is likely that diet and lifestyle plays a part, and it has recently been accepted that previous antibiotic use for one or more bladder infection may kill E.coli but leave fragments of the bacteria bio-molecularly attached to lining of bladder and urinary tract. This can cause long-term irritation of the bladder, making it painful to fill the bladder completely, leading to frequent urination, gradual shrinking of the bladder, and the beginning of a cycle that can be very difficult to break.

The U.S. microbiologist Dr. Paul Fugazzotto, believes that interstitial cystitis is caused by gram-positive bacteria, usually enterococcus, but others believe that gram negative bacteria can also be involved. Our own experience is only with IC related to E.coli and Salmonella.

Top

Possibilities

Waterfall D-Mannose can help to detach bacterial fragments if they are present.
Go here for more information on using the product to help.
As mentioned, dietary changes may help.
Antibiotics seem to bring some relief to some sufferers.
Bladder training to strech the bladder. Try holding it in as long as you can.
Stress reduction, and low-impact exercise are said to reduce symptoms.

Top

Other Treatments and Interventions

Instilling the bladder with with a disinfecting/analgesic solution such as Dimethyl Sulfoxide

Laser treatment to cauterise Hunner’s ulcers can be effective, but the ulcers may return after time.

Acupuncture to help balance the system and ease pain, has proved useful for some, but is ineffective in others.

Transcutaneous electrical nerve stimulation (TENS), which delivers mild electric pulses to the bladder area. This helps relieve pain and urinary frequency in some people.

Top

Surgical interventions for IC- a last resort

Internal Pouch: Urine is diverted to a pouch, constructed from a bowel segment, that is placed inside the abdomen. This is emptied by self-catheterization through a stoma (surgical hole in the abdomen).

Orthotopic Diversion: The bladder is removed and a new bladder, formed from a bowel segment, replaces the damaged bladder. Multiple possible setbacks include bladder stone formation, easier perforation, incontinence, continuing infections or IC, and increased mucus production.

Augmentation Cystoplasty: Removal of part or most of the bladder, and replacment with bowel tissue.

Urinary Diversion: A short section of bowel and the ureters is used to bypass the bladder into an external collection bag. May or may not result in the elimination of pain.

Top

Conclusion

Interstitial Cystitis is a very painful and difficult problem, and we know that Waterfall D-Mannose cannot solve the problem for all IC/PBS sufferers. It does seem to work to clear some of these problems over a 3 month treatment period, if taken at at quite high dose levels. (2 to 4 heaped teaspoons a day). For more information on this see Interstitial Cystitis - A way Forward


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Add to Favourites Home Why we care User Feedback Questions About Sweet Cures Press Releases Order More about E.coli Understanding Repeat infections News E.coli loves cranberry Research Contact Us How to use Waterfall D-Mannose Our Affiliation Programme Traders and Resellers John's Blog Relationship hurting? Get a naturally pure product that is showing itself to be a very effective weapon against cystitis and UTI problems. 50 grams Flat Pack 50 grams Tub 100 x 0.5g Tablets	Understanding repeat E.coli related cystitis, bladder infections, and UTI's. (Go to short version) (Printable Version) We have learned a lot from our customers and from our own experiences and research about the causes of repeat urinary infections, particularly related to E.coli, and the results are interesting for anyone who wants to learn how to avoid such infections. Introduction E.coli survive antibiotic attack Asexual Survival Characteristics (E.coli) Variant E.coli and Antibiotic Resistance Implications and Avoidance Triggers for dormant E.coli release Antibiotic dose levels Causes of fresh or first contamination Recognising Interstitial Cystitis Triggers for Interstitial Cystitis (IC) Other Treatments and Interventions Surgical interventions for IC- a last resort Conclusion Introduction: Until very recently it was thought that each new bladder infection (referring to all areas from the urethra to the kidneys) was the result of a fresh contamination via (usually) the urethra, or sexual contact. However, Sweet Cures has been leading a campaign to change this view. Clearly, there must be a first time for such contamination and infection, but in the vast majority of cases, (though not all) apparently repeat infections are the result of E.coli that survived the previous infection, and have been dormant in the bladder [Proof!] until stimulated into releasing pods from their colony to once again multiply out of control. E.coli are uniquely adapted super mutators. E.coli survive antibiotic attack There is good evidence for this, although not many doctors appear to have taken it on board yet (from the number of women who tell us that their doctor keeps lecturing them on personal hygiene.) When you actually sit down and think about the pattern of most repeat infections, logic leads you to the same conclusions. Darwin'sSurvival of the Species through Natural Selection explains the process through higher forms of life, and E.coli survives as a life form in the same way that we have evolved as humans - by survival of the fittest. Every medical practitioner and every cystitis sufferer knows that E.coli become increasingly resistant to antibiotics used against them. It is important for the understanding of how antibiotic resistance takes place to realise that it's not your body that builds up a resistance to antibiotics, it is the infection agent - in the case of bladder infections, usually E.coli. Top Here is how that works: Asexual Survival Characteristics (E.coli) Say you start off with a strain called x... If you kill all of x with an antibiotic, then there are no x survivors, and if you were to again be infected with x (as a fresh contamination), and took the same antibiotic, there could be no increase in the resistance of x. It would be just like the first time, and they would be all killed. But this is where natural selection comes in. E.coli are asexual organisms with natural variation in the genetic makup of some of the bacteria in every colony. In effect E.coli are genetic clones of each other, but there are occasional mutations that produce genetic variation, giving the variation different survival capabilities. For example, although some of the mutations will have poor survival capabilities, some E.coli in every colony may be able to survive unusual heat, cold, toxin levels, antibiotic attack, or high acidity or alkalinity. They pass on these survival characteristics to their progeny. Doctors attempt to fight the resistance of E.coli by varying the antibiotics used, and by increasing antibiotic dose levels to compensate for the resistance effect, but this only exasperates the problem as the E.coli become increasingly resistant, even to broad-spectrum antibiotics. The result is seriously resistant E.coli that only something that defeats the E.coli in another way (like Waterfall D-Mannose) can get rid of from your body. Top Variant E.coli and Antibiotic Resistance The mechanism of E.coli antibiotic resistance is that one or more natural E.coli variants, (lets call it variant xy), survives the antibiotic attack. For example, by not succumbing to fluorine poisoning. So the antibiotic kills off all x colonies, and xy is left to multiply and establish colonies of it's own, passing on its resistance to fluorine (or whatever toxin the antibiotic utilised) to its duplicates. Most of the xy colonies will be xy type variant, and we already know that xy variant can survive the antibiotic that killed all its x brothers. It's a born survivor. You can't use what you used to kill x, to kill xy - at least not at the same dose levels or not for the same treatment length. So you'll need a longer course of antibiotics or at a stronger dose level to kill xy. And don't forget, xy will have its own variants. Somewhere, there will be an xz variant that can survive these bigger doses. Lets look at the logic again: We know for a fact that E.coli builds up resistance to any antibiotic used against it. It can only do that if some of the bacteria survive the antibiotic attack. If your second episode of cystitis is simply a fresh contamination of the same E.coli that you were previously contaminated with, we are not talking about mutated survivors of the antibiotic, we are talking about the plain old original bug again, so the same dose level of the same antibiotic will work as well as it did before. However, that is not how the course of repeated cystitis attacks works. Typically, infection becomes more and more frequent. Patients go back for more antibiotics. Doctors find that the same dose level doesn't work, so they increase the dose levels, and increase the number treatment days. Or they vary the antibiotic. Gradually, they have to move on to big hitting fluorotoxins like Ciprofloxacin. See Business Week Cipro: Now for the Downside Thus, increasing resistance could not happen if the cystitis were the result of fresh E.coli contamination of non-resistant bugs through faecal contamination or introduced through a sexual partner, or by any other route. Resistance occurs because of survival of the fittest - survival from a previous contamination. Logic therefore tells us that resistant E.coli is left in the bladder after treatment with antibiotics. Fact tells us that it's detectable six weeks later in 35% of women. A year later it has recurred in half of all antibiotic treated women. "Although antibiotics initially sterilize the urine in almost all patients, bacteriuria recurs in approximately one-half by one year." Approach to the Patient with Asymptomatic Bacteriuria, Thomas Fekete, MD, Professor of Medicine and Microbiology, Temple University School of Medicine. Less detectable, but still present, are E.coli living behind biofilms in the bladder, because they don't show up in urine tests. [Proof!] Also see: Dynamic interactions between host and pathogen during acute urinary tract infections. Top Implications and Avoidance From the fact that if you are suffering from repeat episodes of cystitis, E.coli are probably living in your bladder, dormant or not, it is apparent that it is more difficult to avoid than it would be if the problem were simply cross-infection, or poor hygiene. And anyway, once you've had an episode or two of cystitis you'll be obsessively clean. What we've found is that there can be a number of triggers that lead to the next episode - a number of triggers that lead to the reactivation of dormant E.coli already in the bladder, or the release of E.coli pods from behind biofilms in the bladder (the biofilms are made of the same stuff as your bladder wall.) The triggers for dormant E.coli release and causes of fresh contamination also differ, although there is some crossover. Whatever caused that very first infection, it is what makes new or apparently new that is important to sufferers. Triggers for dormant E.coli release: Previous history of infection and antibiotic use. The more recent the use of antibiotics, the greater the probability that an infection is caused by dormant E.coli being released. Dehydration (allows high concentration of uric acid. E.coli seems able to sense when conditions are right for multiplication. It thrives in an acid environment, and even releases its own acid.) Beware of drinking too much coffee or alcohol. If you have a dry mouth, you are probably dehydrated. Acidic urine through drinking acidifying drinks like orange juice or cranberry. Cranberry tablets have the same effect. (Although they contain a small amount of D-Mannose, this is not enough to stop infections. The acidifying effect just makes E.coli infections worse, although cranberry can be useful for Proteous infections.) Sexual intercourse or other stimulation of the bladder, such as by vigorous exercise. This can even trigger long-dormant E.coli pods to begin releasing E.coli into the bladder, for example, even if you have not had sex for ten years, you can get 'honeymoon cystitis' when you next have sex. Various spices with properties that allow them to get into the urine and act as an irritant. Top Antibiotic dose levels With dormant E.coli release, taking the same level of antibiotic over the same period as your previous infection is unlikely to clear the problem, and will make the infection more resistant through the process of natural selection. Taking a higher or longer dose of antibiotics is likely to clear the current episode of cystitis, but produce more resistant dormant E.coli, making your next episode even harder to clear. Top Causes of fresh or first contamination: Insufficient cleaning after toileting (the old wipe from front to back thing...) Unhygienic sexual intercourse. Make sure you are both clean. Oral sex. The mouth and nose harbours E.coli amongst many other bugs. Kissing your partner before he performs cunnilingus can lead to your own mouth bacteria getting up your urethra. Catheterisation. Even exposure to the air for a few seconds with a fresh catheter is enough to contaminate it. Internal examinations. Bacteria are everywhere, so that speculum that's been kindly warmed up on a radiator is probably not a good idea. And anyway, E.coli can survive boiling, (and those that do are really tough little guys) so is the speculum really clean in the first place? If you are actually suffering from bacterial infection, and not from a blockage or gynocological problem, it should be possible from the above to understand what is causing repeat bladder infections or UTI's, and that is a good place to start fighting them. Top Recognising Interstitial Cystitis This is a huge subject area, which we can only touch on lightly here. A huge number of bladder problems, ranging from painless but frequent urination through to severely crippling and debilitating bladder pain that gets worse as the bladder gets full, are labelled under the general heading of 'interstitial cystitis'. "It's a non malignant, non infective condition which may be associated with changes that are apparent when you look at the bladder, but sometimes the bladder may appear absolutely normal, [although] the patient may be crippled with discomfort." Dr Helen O'Connell, consultant urologist - Royal Melbourne Hospital. Other possible causes of the symptoms found in IC include physical abnormalities such as prolapse of the bladder, vaginal infections, urinary tract infections or disorders, endometriosis, bladder cancer, sexually transmitted diseases, and kidney stones. Tests may be necessary to rule out these causes. When blockages, physical abnormalities, and symptom-causing diseases are ruled out, the absence of infection, when combined with pain or frequent urination, is the over-riding factor that can lead to a diagnosis of interstitial cystitis. There may also be one or more of the following. Some level of incontinence. Women's symptoms often get worse during their periods. Pain during sex. Irritation of bladder lining may be apparent when viewed through camera. Pinpoint bleeding in the bladder. Blood or pus in urine, with or without pain. Microscopic examination of 'spots' in bladder wall may reveal fragments of dead bacteria. Small ulcers (Hunner’s ulcers ) covering entire inside of bladder or isolated areas. Raised histamine levels may indicate that some allergic reaction is taking place. Dormant E.coli colonies surviving inside lining of bladder. Top Triggers for Interstitial Cystitis (IC) Some people believe that certain foods such as tomatoes, spices, alcohol, chocolate, caffeinated and citrus beverages, and high-acid foods may add to bladder irritation and inflammation. Others notice that their symptoms get worse after eating or drinking products containing artificial sweeteners. If you believe that your interstitial cystitis is related to your diet, try keeping a diary of food and symptoms. Or try cutting out all of the above, and gradually introducing them to see what is the trigger. Unfortunately, the triggers are not always detectable. Interstitial cystitis can affect otherwise healthy individuals for no apparent reason. However, it is likely that diet and lifestyle plays a part, and it has recently been accepted that previous antibiotic use for one or more bladder infection may kill E.coli but leave fragments of the bacteria bio-molecularly attached to lining of bladder and urinary tract. This can cause long-term irritation of the bladder, making it painful to fill the bladder completely, leading to frequent urination, gradual shrinking of the bladder, and the beginning of a cycle that can be very difficult to break. The U.S. microbiologist Dr. Paul Fugazzotto, believes that interstitial cystitis is caused by gram-positive bacteria, usually enterococcus, but others believe that gram negative bacteria can also be involved. Our own experience is only with IC related to E.coli and Salmonella. Top Possibilities Waterfall D-Mannose can help to detach bacterial fragments if they are present. Go here for more information on using the product to help. As mentioned, dietary changes may help. Antibiotics seem to bring some relief to some sufferers. Bladder training to strech the bladder. Try holding it in as long as you can. Stress reduction, and low-impact exercise are said to reduce symptoms. Top Other Treatments and Interventions Instilling the bladder with with a disinfecting/analgesic solution such as Dimethyl Sulfoxide "Having this instilled in my bladder for 3 weeks was the single worst thing I have ever done for my IC. I ended up in hospital on pethidine for pain control and then was laid up for nearly 6 months before the pain level went down to where it was before the instillation." Katie Lauren Smith on RemedyFind Laser treatment to cauterise Hunner’s ulcers can be effective, but the ulcers may return after time. Acupuncture to help balance the system and ease pain, has proved useful for some, but is ineffective in others. Transcutaneous electrical nerve stimulation (TENS), which delivers mild electric pulses to the bladder area. This helps relieve pain and urinary frequency in some people. Top Surgical interventions for IC- a last resort Internal Pouch: Urine is diverted to a pouch, constructed from a bowel segment, that is placed inside the abdomen. This is emptied by self-catheterization through a stoma (surgical hole in the abdomen). Orthotopic Diversion: The bladder is removed and a new bladder, formed from a bowel segment, replaces the damaged bladder. Multiple possible setbacks include bladder stone formation, easier perforation, incontinence, continuing infections or IC, and increased mucus production. Augmentation Cystoplasty: Removal of part or most of the bladder, and replacment with bowel tissue. Urinary Diversion: A short section of bowel and the ureters is used to bypass the bladder into an external collection bag. May or may not result in the elimination of pain. Top Conclusion Interstitial Cystitis is a very painful and difficult problem, and we know that Waterfall D-Mannose cannot solve the problem for all IC/PBS sufferers. It does seem to work to clear some of these problems over a 3 month treatment period, if taken at at quite high dose levels. (2 to 4 heaped teaspoons a day). For more information on this see Interstitial Cystitis - A way Forward Top
Disclaimer: Nothing on this page is meant to constitute medical advice. Copyright ©: Sweet Cures, United Kingdom, 2001-Present. All rights reserved.

Understanding repeat E.coli related cystitis, bladder infections, and UTI's.