Urinary Tract Infection (UTI): A Comprehensive Guide from Basic to Advanced

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// ═══════════════════════════════════════════════════════════════════
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 2 — OVERVIEW / TABLE OF CONTENTS
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    ["2", "Describe the normal host defense mechanisms of the urinary tract"],
    ["3", "Explain the virulence factors of uropathogenic E. coli (UPEC)"],
    ["4", "Trace the step-by-step ascending pathogenesis from colonization to pyelonephritis"],
    ["5", "Describe intracellular bacterial communities (IBCs) and recurrence mechanisms"],
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 3 — DEFINITION & CLASSIFICATION
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 4 — HOST DEFENSE MECHANISMS
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 5 — VIRULENCE FACTORS OF UPEC (visual table)
// ═══════════════════════════════════════════════════════════════════
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    { name: "P-Fimbriae\n(Mannose-Resistant)", mech: "Bind Gal-Gal (globoside) receptors on urothelium + renal tubules", outcome: "Critical for upper tract ascent → PYELONEPHRITIS", role: "Upper tract virulence" },
    { name: "S-Fimbriae &\nDr Fimbriae", mech: "Bind sialoglycoprotein & Dr blood group antigen on kidney cells", outcome: "Bind to Bowman's capsule — associated with recurrent cystitis in pregnancy", role: "Adhesion" },
    { name: "Hemolysin (HlyA)", mech: "Pore-forming toxin — inserts into host cell membranes", outcome: "Lyses RBCs and urothelial cells → releases iron, nutrients & damages vasculature", role: "Cytotoxin / Iron acquisition" },
    { name: "Aerobactin\n(Siderophore)", mech: "High-affinity iron chelator secreted into urine", outcome: "Scavenges iron from host proteins (lactoferrin, transferrin) — essential for survival in iron-poor urine", role: "Iron acquisition" },
    { name: "Serum Resistance\n(O-Antigen / K-Antigen)", mech: "Thick polysaccharide capsule (K antigen) and LPS O-antigen", outcome: "Resists complement-mediated killing; evades opsonization — allows bacteremia in urosepsis", role: "Immune evasion" },
    { name: "Cytotoxic\nNecrotizing Factor (CNF1)", mech: "Activates Rho GTPases in host cells", outcome: "Promotes bacterial internalization and suppresses apoptosis — prolongs intracellular survival", role: "Invasion" },
    { name: "Type VI Secretion\nSystem (T6SS)", mech: "Injects toxic effectors into competing bacteria", outcome: "Kills competing microbiota → gives UPEC competitive advantage in bladder colonization", role: "Competition / Colonization" },
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 6 — ASCENDING PATHOGENESIS (with diagram)
// ═══════════════════════════════════════════════════════════════════
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    { n: "3", t: "Bladder Infection (Cystitis)", b: "Bacterial multiplication in stasis urine. Host mounts innate immune response (neutrophil influx, IL-8, TLR4 signaling). Symptoms: dysuria, frequency, urgency." },
    { n: "4", t: "Vesicoureteral Reflux (VUR)", b: "Incompetent ureterovesical valve allows infected urine to reflux into ureters. Present in 20–40% of children with UTI. Also seen in neurogenic bladder, spinal cord injury." },
    { n: "5", t: "Renal Ascent → Pyelonephritis", b: "Bacteria reach renal pelvis. P-fimbriae bind Gal-Gal on renal tubular cells. Suppurative inflammation: neutrophil-filled tubules, discrete cortical abscesses, WBC casts." },
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 7 — HEMATOGENOUS ROUTE & RISK FACTORS
// ═══════════════════════════════════════════════════════════════════
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  slideTitle(s, "Hematogenous Route & Key Risk Factors");

  // Left: hematogenous
  card(s, 0.45, 0.92, 4.2, 2.55, C.navyMid);
  s.addText("⬇  HEMATOGENOUS (DESCENDING) ROUTE", {
    x: 0.65, y: 0.98, w: 3.9, h: 0.32,
    fontSize: 9, bold: true, color: C.red, charSpacing: 0.5, margin: 0
  });
  s.addText("~5% of UTIs — bacteria seed kidneys from bloodstream", {
    x: 0.65, y: 1.28, w: 3.9, h: 0.28,
    fontSize: 9, italic: true, color: C.lightGray, margin: 0
  });
  const hematoItems = [
    "Common agents: Staphylococcus aureus (endocarditis), E. coli (gram-negative sepsis)",
    "Creates discrete cortical foci of pyelonephritis — not contiguous with pelvis initially",
    "Suspect when no lower UTI symptoms precede upper tract disease",
    "Associated with IV drug use, infected indwelling venous lines, immunosuppression",
    "Candida UTI is usually hematogenous in ICU / immunocompromised patients",
  ];
  s.addText(hematoItems.map(i => "▸  " + i).join("\n"), {
    x: 0.65, y: 1.58, w: 3.8, h: 1.72,
    fontSize: 9, color: C.offWhite, margin: 0, wrap: true
  });

  // Right: comparison table
  card(s, 4.85, 0.92, 4.7, 2.55, C.navyMid);
  s.addText("ASCENDING vs HEMATOGENOUS — COMPARISON", {
    x: 5.02, y: 0.98, w: 4.4, h: 0.28,
    fontSize: 8.5, bold: true, color: C.accent, charSpacing: 0.3, margin: 0
  });
  const compRows = [
    ["Feature", "Ascending", "Hematogenous"],
    ["Frequency", "~95%", "~5%"],
    ["Route", "Urethra → Bladder → Kidney", "Bloodstream → Kidney"],
    ["Common agents", "E. coli, Proteus, Klebsiella", "S. aureus, Candida, E. coli"],
    ["Initial site", "Bladder / lower tract first", "Cortex (discrete foci)"],
    ["Association", "VUR, catheter, pregnancy", "Sepsis, endocarditis, IVDU"],
  ];
  compRows.forEach((row, ri) => {
    const isHeader = ri === 0;
    const yRow = 1.3 + ri * 0.36;
    const fills = [C.steel, C.steelLight, C.midGray];
    const widths = [1.1, 1.7, 1.7];
    const xStart = [5.02, 6.15, 7.88];
    row.forEach((cell, ci) => {
      s.addShape(pres.shapes.RECTANGLE, {
        x: xStart[ci], y: yRow, w: widths[ci], h: 0.34,
        fill: { color: isHeader ? C.steel : (ri % 2 === 0 ? C.navyMid : C.navy) },
        line: { color: C.steel, pt: 0.3 }
      });
      s.addText(cell, {
        x: xStart[ci] + 0.05, y: yRow, w: widths[ci] - 0.08, h: 0.34,
        fontSize: isHeader ? 8 : 8, bold: isHeader, color: isHeader ? C.white : C.offWhite,
        valign: "middle", margin: 0
      });
    });
  });

  // Bottom: risk factor grid
  s.addText("KEY RISK FACTORS FOR UTI", {
    x: 0.45, y: 3.62, w: 5, h: 0.28,
    fontSize: 9.5, bold: true, color: C.accent, charSpacing: 2, margin: 0
  });
  const riskFactors = [
    { cat: "Anatomical", items: "Short urethra (F), VUR, urethral stricture, BPH, posterior urethral valves" },
    { cat: "Behavioral", items: "Sexual intercourse, spermicide use, new sexual partner, poor voiding habits" },
    { cat: "Metabolic", items: "Diabetes mellitus (glycosuria, neurogenic bladder), SGLT-2 inhibitors (glycosuria)" },
    { cat: "Iatrogenic", items: "Urinary catheter, cystoscopy, nephrostomy tube, ureteral stent" },
    { cat: "Hormonal", items: "Estrogen deficiency (postmenopause) → loss of Lactobacillus protection" },
    { cat: "Immune", items: "Immunosuppression, transplant, neutropenia, HIV/AIDS" },
  ];
  riskFactors.forEach((rf, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.45 + col * 3.15;
    const y = 3.98 + row * 0.58;
    s.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 3.0, h: 0.52,
      fill: { color: C.navyMid }, line: { color: C.steel, pt: 0.4 }
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 0.06, h: 0.52,
      fill: { color: C.accent }, line: { color: C.accent }
    });
    s.addText(rf.cat + ": ", {
      x: x + 0.15, y: y + 0.04, w: 0.85, h: 0.24,
      fontSize: 8.5, bold: true, color: C.accentLight, margin: 0
    });
    s.addText(rf.items, {
      x: x + 0.15, y: y + 0.26, w: 2.75, h: 0.24,
      fontSize: 8, color: C.lightGray, margin: 0
    });
  });
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 8 — INTRACELLULAR BACTERIAL COMMUNITIES (IBCs)
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);
  slideTitle(s, "Intracellular Bacterial Communities (IBCs) & Recurrence");

  s.addText("Why does UTI recur? The IBC pathway explains recurrent cystitis in the absence of re-infection.", {
    x: 0.45, y: 0.9, w: 9.1, h: 0.35,
    fontSize: 10.5, italic: true, color: C.lightGray, margin: 0
  });

  // IBC lifecycle steps — horizontal flow
  const ibcSteps = [
    { n: "1", title: "Attachment", body: "Type 1 fimbriae bind FimH to uroplakin Ia/Ib on urothelial surface", color: C.steelLight },
    { n: "2", title: "Invasion", body: "UPEC triggers actin rearrangement → zip-up mechanism → endocytosis into umbrella cell", color: C.steelLight },
    { n: "3", title: "IBC Formation", body: "Bacteria replicate rapidly inside vesicle → 10⁴–10⁵ bacteria form biofilm-like pod (\"IBC\") within 6 hrs", color: C.accent },
    { n: "4", title: "Dispersal", body: "IBCs disperse, bacteria egress, flux into underlying transitional cells → establish Quiescent Intracellular Reservoirs (QIRs)", color: C.accent },
    { n: "5", title: "QIR Reactivation", body: "QIRs remain dormant for weeks–months. Triggered by estrogen, stress or antibiotic exposure → seeding of recurrent UTI", color: C.red },
  ];

  ibcSteps.forEach((step, i) => {
    const x = 0.38 + i * 1.9;
    const y = 1.35;
    card(s, x, y, 1.75, 2.4, C.navyMid);
    s.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 1.75, h: 0.08,
      fill: { color: step.color }, line: { color: step.color }
    });
    s.addShape(pres.shapes.ELLIPSE, {
      x: x + 0.65, y: y + 0.18, w: 0.45, h: 0.45,
      fill: { color: step.color }, line: { color: step.color }
    });
    s.addText(step.n, {
      x: x + 0.65, y: y + 0.16, w: 0.45, h: 0.45,
      fontSize: 14, bold: true, color: C.white,
      align: "center", valign: "middle", margin: 0
    });
    s.addText(step.title, {
      x: x + 0.1, y: y + 0.72, w: 1.56, h: 0.32,
      fontSize: 10, bold: true, color: C.white, align: "center", margin: 0
    });
    s.addText(step.body, {
      x: x + 0.1, y: y + 1.06, w: 1.56, h: 1.25,
      fontSize: 8.5, color: C.offWhite, align: "left", margin: 0, wrap: true
    });
    // arrow
    if (i < 4) {
      s.addShape(pres.shapes.RECTANGLE, {
        x: x + 1.75, y: y + 1.15, w: 0.14, h: 0.05,
        fill: { color: C.accent }, line: { color: C.accent }
      });
    }
  });

  // Clinical implication box
  card(s, 0.38, 3.9, 9.25, 1.15, C.steel);
  s.addText("⚠  CLINICAL IMPLICATIONS OF IBC BIOLOGY", {
    x: 0.58, y: 3.95, w: 8.8, h: 0.3,
    fontSize: 9.5, bold: true, color: C.white, charSpacing: 1.5, margin: 0
  });
  s.addText([
    { text: "• Short-course antibiotics kill extracellular bacteria but do NOT eliminate QIRs → explains why 3-day courses cure but may not prevent recurrence  ", options: { color: C.offWhite } },
    { text: "• Fluoroquinolones penetrate cells better than β-lactams → preferred for preventing IBC-driven recurrence  ", options: { color: C.offWhite } },
    { text: "• Novel targets: FimH antagonists (mannosides) block type 1 fimbriae adhesion — currently in clinical trials", options: { color: C.accentLight, bold: true } },
  ], {
    x: 0.58, y: 4.28, w: 8.9, h: 0.72,
    fontSize: 9, margin: 0, wrap: true
  });
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 9 — CLINICAL FEATURES & DIAGNOSIS
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);
  slideTitle(s, "Clinical Features & Diagnosis");

  // Lower UTI
  card(s, 0.45, 0.92, 4.2, 4.2, C.navyMid);
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.45, y: 0.92, w: 4.2, h: 0.1,
    fill: { color: C.steelLight }, line: { color: C.steelLight }
  });
  s.addText("LOWER UTI (CYSTITIS)", {
    x: 0.62, y: 0.98, w: 3.9, h: 0.3,
    fontSize: 10, bold: true, color: C.steelLight, charSpacing: 1, margin: 0
  });
  const lowerSymptoms = [
    ["Dysuria", "Burning / pain on urination — most common complaint"],
    ["Frequency", "Urinating more often than usual (>8×/day)"],
    ["Urgency", "Sudden compelling need to void — may be unable to defer"],
    ["Suprapubic pain", "Pressure/discomfort over bladder, lower abdomen"],
    ["Hematuria", "Frank or microscopic blood in urine"],
    ["Cloudy urine", "Turbid due to pyuria; malodorous from bacterial metabolites"],
    ["Nocturia", "Waking at night to urinate"],
  ];
  lowerSymptoms.forEach(([sym, desc], i) => {
    const y = 1.38 + i * 0.5;
    s.addShape(pres.shapes.RECTANGLE, {
      x: 0.62, y: y + 0.12, w: 0.06, h: 0.22,
      fill: { color: C.steelLight }, line: { color: C.steelLight }
    });
    s.addText(sym + ":", {
      x: 0.8, y: y + 0.05, w: 1.0, h: 0.25,
      fontSize: 9, bold: true, color: C.white, margin: 0
    });
    s.addText(desc, {
      x: 0.8, y: y + 0.26, w: 3.65, h: 0.22,
      fontSize: 8, color: C.lightGray, margin: 0
    });
  });
  s.addText("⚠  No systemic fever in uncomplicated cystitis — fever = upper tract involvement until proven otherwise", {
    x: 0.62, y: 4.85, w: 3.9, h: 0.24,
    fontSize: 8, italic: true, color: C.accent, margin: 0
  });

  // Upper UTI + Diagnosis
  card(s, 4.85, 0.92, 4.7, 2.0, C.navyMid);
  s.addShape(pres.shapes.RECTANGLE, {
    x: 4.85, y: 0.92, w: 4.7, h: 0.1,
    fill: { color: C.red }, line: { color: C.red }
  });
  s.addText("UPPER UTI (PYELONEPHRITIS)", {
    x: 5.02, y: 0.98, w: 4.4, h: 0.3,
    fontSize: 10, bold: true, color: C.red, charSpacing: 1, margin: 0
  });
  const upperSymptoms = [
    "🌡  Fever >38.5°C with rigors and chills — sudden onset",
    "📍  Costovertebral angle (CVA) tenderness — loin/flank pain",
    "🤢  Nausea, vomiting, malaise, headache",
    "💧  Lower tract symptoms (dysuria, frequency) often co-exist",
    "🔬  Turbid urine with WBC casts (pathognomonic)",
    "⚡  Risk of urosepsis if untreated — requires IV antibiotics",
  ];
  s.addText(upperSymptoms.join("\n"), {
    x: 5.02, y: 1.34, w: 4.45, h: 1.48,
    fontSize: 8.5, color: C.offWhite, margin: 0, wrap: true
  });

  // Diagnosis box
  card(s, 4.85, 3.07, 4.7, 2.05, C.navyMid);
  s.addText("DIAGNOSTIC WORKUP", {
    x: 5.02, y: 3.13, w: 4.4, h: 0.28,
    fontSize: 9.5, bold: true, color: C.accent, charSpacing: 1.5, margin: 0
  });
  const diagRows = [
    { test: "Urinalysis (dipstick)", findings: "Nitrite +, leukocyte esterase +, hematuria", level: "1st" },
    { test: "Urine Microscopy", findings: "Pyuria (>5 WBC/hpf), WBC casts = pyelonephritis", level: "1st" },
    { test: "Urine Culture (gold standard)", findings: "≥10⁵ CFU/mL; guides antibiotic choice", level: "1st" },
    { test: "Blood culture + CBC/CRP", findings: "If sepsis suspected; leukocytosis + elevated CRP", level: "2nd" },
    { test: "CT / Ultrasound", findings: "Obstruction, abscess, stones, hydronephrosis", level: "2nd" },
  ];
  diagRows.forEach((d, i) => {
    const y = 3.5 + i * 0.32;
    pill(s, 4.95, y, 0.35, 0.26, d.level, d.level === "1st" ? C.steelLight : C.midGray, C.white, 7);
    s.addText(d.test + ": ", {
      x: 5.42, y: y + 0.02, w: 1.7, h: 0.24,
      fontSize: 8, bold: true, color: C.white, margin: 0
    });
    s.addText(d.findings, {
      x: 7.15, y: y + 0.02, w: 2.2, h: 0.24,
      fontSize: 8, color: C.lightGray, margin: 0
    });
  });
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 10 — COMPLICATIONS & PATHOLOGY (with image)
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);
  slideTitle(s, "Pathological Complications of UTI");

  s.addText("Untreated or recurrent UTI can progress to severe renal pathology — these findings are examinable:", {
    x: 0.45, y: 0.9, w: 9.1, h: 0.35,
    fontSize: 10, italic: true, color: C.lightGray, margin: 0
  });

  // Pathology image (pyelonephritis gross + histology)
  s.addImage({
    data: pyeloImg,
    x: 5.2, y: 1.35, w: 4.45, h: 3.0
  });
  card(s, 5.2, 4.38, 4.45, 0.65, C.navyMid);
  s.addText("FIG: Acute Pyelonephritis (Robbins & Kumar Basic Pathology)\n(A) Gross: yellowish cortical abscesses. (B) Micro: neutrophil-filled tubules (pyonephrosis).", {
    x: 5.32, y: 4.42, w: 4.2, h: 0.58,
    fontSize: 7.5, italic: true, color: C.lightGray, margin: 0
  });

  // Complications list
  const complications = [
    { name: "Acute Pyelonephritis", desc: "Suppurative inflammation: discrete yellowish cortical abscesses, neutrophils in tubules + interstitium, WBC casts", severity: "Moderate" },
    { name: "Perinephric Abscess", desc: "Pus outside kidney capsule. Often needs CT-guided drainage. Present with fever not responding to antibiotics", severity: "Severe" },
    { name: "Pyonephrosis", desc: "Obstruction + infection = collecting system fills with pus. Surgical/urological emergency — nephrostomy required", severity: "Severe" },
    { name: "Papillary Necrosis", desc: "Ischemic + suppurative necrosis of renal papillae. Classic triad: diabetes + obstruction + sickle cell anemia", severity: "Severe" },
    { name: "Urosepsis", desc: "Gram-negative bacteremia + endotoxemia (LPS → septic shock cascade). Mortality >20%. Treat with IV broad-spectrum ABx ± ICU", severity: "Critical" },
    { name: "Chronic Pyelonephritis / CKD", desc: "Recurrent infections → irregular corticomedullary scars + calyceal deformity → progressive CKD + hypertension", severity: "Chronic" },
    { name: "Emphysematous Pyelonephritis", desc: "Gas-forming infection of renal parenchyma; 90% in diabetics; life-threatening surgical emergency", severity: "Critical" },
  ];

  const sevColor = { Moderate: C.steelLight, Severe: C.accent, Critical: C.red, Chronic: C.midGray };
  complications.forEach((c, i) => {
    const y = 1.35 + i * 0.58;
    s.addShape(pres.shapes.RECTANGLE, {
      x: 0.45, y, w: 4.5, h: 0.52,
      fill: { color: C.navyMid }, line: { color: C.steel, pt: 0.3 }
    });
    pill(s, 0.5, y + 0.12, 0.72, 0.26, c.severity, sevColor[c.severity] || C.midGray, C.white, 7);
    s.addText(c.name, {
      x: 1.3, y: y + 0.05, w: 3.5, h: 0.22,
      fontSize: 8.5, bold: true, color: C.white, margin: 0
    });
    s.addText(c.desc, {
      x: 1.3, y: y + 0.27, w: 3.5, h: 0.22,
      fontSize: 7.5, color: C.lightGray, margin: 0
    });
  });
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 11 — TREATMENT PRINCIPLES
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);
  slideTitle(s, "Treatment Principles");

  // Antibiotic table header
  s.addText("EMPIRICAL ANTIBIOTIC SELECTION — MATCHED TO SEVERITY", {
    x: 0.45, y: 0.9, w: 9.1, h: 0.32,
    fontSize: 9.5, bold: true, color: C.accent, charSpacing: 1.5, margin: 0
  });

  const tableRows = [
    { type: "Uncomplicated Cystitis", abx: "TMP-SMX 160/800 mg BD × 3 days; Nitrofurantoin 100 mg BD × 5 days; Fosfomycin 3 g × 1 dose", notes: "Fluoroquinolones NOT first-line (reserve for complicated infections)", tier: "1st" },
    { type: "Mild Pyelonephritis\n(outpatient)", abx: "Ciprofloxacin 500 mg BD × 7 days; TMP-SMX × 14 days; Levofloxacin 750 mg OD × 5 days", notes: "If tolerating orals, no vomiting, afebrile after 24–48h", tier: "2nd" },
    { type: "Severe Pyelonephritis\n(inpatient)", abx: "IV Ciprofloxacin 400 mg q8–12h; IV Ceftriaxone 1–2 g OD; Aminoglycosides (gentamicin, amikacin)", notes: "Get blood + urine cultures before starting. Switch to oral when afebrile 24h", tier: "3rd" },
    { type: "Complicated UTI /\nPseudomonas", abx: "Piperacillin-tazobactam 4.5 g q8h; Meropenem 1 g q8h; Ceftazidime-avibactam; Ceftolozane-tazobactam", notes: "Base choice on local antibiogram. Remove/replace catheter or stent", tier: "MDR" },
    { type: "UTI in Pregnancy", abx: "Cephalexin 500 mg BD × 7 days; Nitrofurantoin (avoid 3rd trimester); Amoxicillin 500 mg TID × 7 days", notes: "Screen ALL pregnant women at 12–16 weeks. Up to 30% bacteriuria → pyelonephritis if untreated", tier: "Preg" },
  ];

  const tierColors = { "1st": C.green, "2nd": C.steelLight, "3rd": C.accent, "MDR": C.red, "Preg": C.steelLight };

  const colXs = [0.45, 1.3, 5.1, 7.85];
  const colWs = [0.82, 3.75, 2.7, 1.85];
  const headers = ["TIER", "UTI TYPE", "ANTIBIOTIC OPTIONS", "NOTES / CAUTIONS"];

  headers.forEach((h, ci) => {
    s.addShape(pres.shapes.RECTANGLE, {
      x: colXs[ci], y: 1.3, w: colWs[ci], h: 0.35,
      fill: { color: C.steel }, line: { color: C.steelLight, pt: 0.4 }
    });
    s.addText(h, {
      x: colXs[ci] + 0.06, y: 1.3, w: colWs[ci] - 0.08, h: 0.35,
      fontSize: 8.5, bold: true, color: C.white, valign: "middle", margin: 0
    });
  });

  tableRows.forEach((row, ri) => {
    const y = 1.65 + ri * 0.68;
    const bg = ri % 2 === 0 ? C.navyMid : C.navy;
    colXs.forEach((cx, ci) => {
      s.addShape(pres.shapes.RECTANGLE, {
        x: cx, y, w: colWs[ci], h: 0.65,
        fill: { color: bg }, line: { color: C.steel, pt: 0.3 }
      });
    });
    pill(s, colXs[0] + 0.08, y + 0.18, 0.62, 0.28, row.tier, tierColors[row.tier] || C.midGray, C.white, 8);
    s.addText(row.type, { x: colXs[1] + 0.08, y: y + 0.05, w: colWs[1] - 0.12, h: 0.62, fontSize: 8.5, bold: true, color: C.white, valign: "middle", margin: 0, wrap: true });
    s.addText(row.abx, { x: colXs[2] + 0.06, y: y + 0.04, w: colWs[2] - 0.1, h: 0.58, fontSize: 7.5, color: C.offWhite, margin: 0, wrap: true });
    s.addText(row.notes, { x: colXs[3] + 0.06, y: y + 0.04, w: colWs[3] - 0.1, h: 0.58, fontSize: 7.5, color: C.lightGray, italic: true, margin: 0, wrap: true });
  });

  // IDSA note
  s.addText("IDSA recommends avoiding antimicrobials when local resistance exceeds 20% — always check institutional antibiogram before empirical prescribing.", {
    x: 0.45, y: 5.07, w: 9.1, h: 0.2,
    fontSize: 8, italic: true, color: C.midGray, margin: 0
  });
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 12 — PREVENTION & KEY TAKEAWAYS
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);
  slideTitle(s, "Prevention & Key Takeaways");

  // Prevention grid
  s.addText("PREVENTION STRATEGIES", {
    x: 0.45, y: 0.9, w: 5.5, h: 0.3,
    fontSize: 9.5, bold: true, color: C.accent, charSpacing: 2, margin: 0
  });

  const preventions = [
    { icon: "💧", title: "Hydration", body: ">1.5–2 L/day — maintains urinary flow, flushes periurethral bacteria" },
    { icon: "🚽", title: "Voiding habits", body: "Void frequently; post-coital voiding; wipe front-to-back (females)" },
    { icon: "🍒", title: "Cranberry", body: "Proanthocyanidins block FimH-mediated adhesion of E. coli to urothelium" },
    { icon: "💊", title: "Antibiotic prophylaxis", body: "Low-dose nightly TMP or nitrofurantoin for ≥3 UTIs/year; post-coital single dose" },
    { icon: "🧫", title: "Vaginal estrogen", body: "Postmenopausal women — restores Lactobacillus, lowers pH, reduces colonization" },
    { icon: "🏥", title: "CAUTI prevention", body: "Aseptic catheter insertion, closed drainage, minimize dwell time, catheter bundles" },
  ];

  preventions.forEach((p, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.45 + col * 1.78;
    const y = 1.28 + row * 1.3;
    card(s, x, y, 1.65, 1.18, C.navyMid);
    s.addText(p.icon, {
      x: x + 0.6, y: y + 0.08, w: 0.5, h: 0.4,
      fontSize: 18, align: "center", margin: 0
    });
    s.addText(p.title, {
      x: x + 0.08, y: y + 0.5, w: 1.5, h: 0.24,
      fontSize: 9, bold: true, color: C.accent, align: "center", margin: 0
    });
    s.addText(p.body, {
      x: x + 0.08, y: y + 0.72, w: 1.5, h: 0.42,
      fontSize: 7.5, color: C.offWhite, align: "left", margin: 0, wrap: true
    });
  });

  // Key takeaways
  s.addText("KEY TAKEAWAYS FOR EXAMS", {
    x: 5.75, y: 0.9, w: 3.9, h: 0.3,
    fontSize: 9.5, bold: true, color: C.accent, charSpacing: 2, margin: 0
  });
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  const takeaways = [
    "E. coli causes 70–95% of uncomplicated UTIs; P-fimbriae = upper tract virulence",
    "Ascending route (~95%) > hematogenous (~5%)",
    "IBCs explain recurrent UTI — QIRs survive short antibiotic courses",
    "VUR (20–40% of children with UTI) is the key predisposing factor for pyelonephritis",
    "First-line uncomplicated cystitis: TMP-SMX × 3 d, nitrofurantoin × 5 d, fosfomycin × 1 dose",
    "Fluoroquinolones: NOT for simple cystitis; reserved for complicated/severe infections",
    "WBC casts in urine = pathognomonic for pyelonephritis",
    "Papillary necrosis triad: diabetes + obstruction + sickle cell anemia",
  ];

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  const refs = [
    "Robbins & Kumar Basic Pathology (Robbins Pathology)",
    "Comprehensive Clinical Nephrology, 7th Edition",
    "Campbell-Walsh-Wein Urology, 3-Volume Set",
    "Rosen's Emergency Medicine, 10th Edition",
    "Berek & Novak's Gynecology",
    "Goldman-Cecil Medicine, International Edition",
  ];
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    { t: "FimH Antagonists (Mannosides)", b: "Block type 1 fimbriae–uroplakin interaction → prevent invasion; phase II trials ongoing" },
    { t: "Phage Therapy", b: "Bacteriophages targeting MDR E. coli for catheter-associated UTI; compassionate use cases reported" },
    { t: "UTI Vaccines", b: "Uromune (OM-89): oral polybacterial vaccine; reduces recurrent UTI rates by ~50% in trials" },
    { t: "SGLT-2 Inhibitors & UTI risk", b: "Glycosuria provides carbon source for E. coli; associated with 1.5× increased UTI risk — important pharmacology link" },
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 13 — CLOSING / THANK YOU
// ═══════════════════════════════════════════════════════════════════
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    "UPEC Type 1 & P-Fimbriae → Adhesion & Upper Tract Invasion",
    "Ascending route: Colonization → Bladder → VUR → Kidney",
    "IBCs → QIRs → Recurrent Cystitis",
    "E. coli 70–95% · S. saprophyticus 5–20%",
    "TMP-SMX / Nitrofurantoin → First-line for cystitis",
    "Complications: Urosepsis · Papillary Necrosis · CKD",
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// ─── WRITE FILE ───────────────────────────────────────────────────
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