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Societal health is facing a number of new challenges, largely driven by ongoing climate change, demographic ageing, and globalization. The One Health approach links human, animal, and environmental sectors with the goal of achieving a holistic understanding of health in general. To implement this approach, diverse and heterogeneous data streams and types must be combined and analyzed. To this end, artificial intelligence (AI) techniques offer new opportunities for cross-sectoral assessment of current and future health threats. Using the example of antimicrobial resistance as a global threat in the One Health context, we demonstrate potential applications and challenges of AI techniques.This article provides an overview of different applications of AI techniques in the context of One Health and highlights their challenges. Using the spread of antimicrobial resistance (AMR), an increasing global threat, as an example, existing and future AI-based approaches to AMR containment and prevention are described. These range from novel drug development and personalized therapy, to targeted monitoring of antibiotic use in livestock and agriculture, to comprehensive environmental surveillance., (© 2023. The Author(s).)

The SARS-CoV‑2 pandemic has shown a deficit of essential epidemiological infrastructure, especially with regard to genomic pathogen surveillance in Germany. In order to prepare for future pandemics, the authors consider it urgently necessary to remedy this existing deficit by establishing an efficient infrastructure for genomic pathogen surveillance. Such a network can build on structures, processes, and interactions that have already been initiated regionally and further optimize them. It will be able to respond to current and future challenges with a high degree of adaptability.The aim of this paper is to address the urgency and to outline proposed measures for establishing an efficient, adaptable, and responsive genomic pathogen surveillance network, taking into account external framework conditions and internal standards. The proposed measures are based on global and country-specific best practices and strategy papers. Specific next steps to achieve an integrated genomic pathogen surveillance include linking epidemiological data with pathogen genomic data; sharing and coordinating existing resources; making surveillance data available to relevant decision-makers, the public health service, and the scientific community; and engaging all stakeholders. The establishment of a genomic pathogen surveillance network is essential for the continuous, stable, active surveillance of the infection situation in Germany, both during pandemic phases and beyond., (© 2023. The Author(s).)

The COVID-19 pandemic once again highlighted the vulnerability of residents of long-term care facilities due to their increased risk of a severe or fatal course of COVID-19. To protect the residents in the face of high incidences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV‑2) in the general population, a number of measures for infection protection were recommended, which led to a decrease of COVID-19 case numbers and deaths in the facilities during the pandemic. However, factors in the facilities that hampered the implementation of these measures and represented a significant impact on the health of the residents also became visible.The challenges concern working conditions (e.g., lack of staff, both in general and with corresponding competencies, and work-related stress), the care of residents (e.g., medical and psychosocial), and structural as well as facility-related factors (e.g., facility size).Approaches to these problems indicate that a successful implementation of infection control measures should be part of a concept for redesigning the work and living conditions of the staff and residents of the facilities. It is important to note that infection control should not be planned exclusively with regard to future pandemics, but is of relevance for health risks that already exist in the facilities, such as healthcare-associated infections, antibiotic resistances, or influenza., (© 2023. The Author(s).)

Background and Objective: The essential role of infection prevention in long-term care facilities has become evident during the current SARS-CoV‑2 pandemic. In order to obtain a reliable database on nosocomial infections and antibiotic use, the European Centre for Disease Prevention and Control (ECDC) initiated the third point prevalence survey in European long-term care facilities from 2016 to 2017 (HALT-3)., Material and Methods: In Germany, 131 facilities with 10,565 residents participated voluntarily. On a single day in 2016, the number of nosocomial infections and/or uses of antibiotics as well as care characteristics and risk factors of the residents were recorded. Infections were documented based on symptoms using an algorithm in accordance with the McGeer surveillance criteria for long-term care facilities., Results: A nosocomial infection was documented in 177 residents, which corresponds to a prevalence of 1.7% (95% CI: 1.3-2.1), still low in comparison with the European prevalence (mean value 3.9%). Urinary tract infections were the most common infections at almost 50%, followed by respiratory, skin, and soft-tissue infections. The type of infection was consistent with the most common indications for antibiotic use. Antibiotic use was documented in 143 residents (prevalence of 1.4%, 95% CI: 1.1-1.7). The frequent use of fluoroquinolones with over 20% of all prescriptions was noticeable., Conclusions: The establishment of facility-based surveillance of the most common infections and antibiotic consumption, together with the creation of guidelines specifically tailored to the geriatric population, could contribute to improving infection prevention and control as well as a more rational use of antibiotics, thus increasing the quality and safety of care., (© 2022. The Author(s).)

In November 2021, the Federal Ministry of Health (BMG) organized the one-day virtual workshop "Rational antibiotic use in the outpatient sector - potential and opportunities for change" with scientific support from the Robert Koch Institute (RKI). The aim was to collect strategies for promoting the appropriate use of antibiotics in the outpatient sector. With 114 participants, important stakeholders of the healthcare system were represented. In the run-up to the event, the invited participants had already been asked to take part in an online survey on perspectives, experiences, and ideas for the rational use of antibiotics in the outpatient sector. The answers were analyzed and presented at the workshop.The workshop was introduced with plenary lectures on the German Antibiotic Resistance Strategy (DART) and the antibiotic resistance situation in Germany. All experts participated in 10 working group discussions; the resulting findings were presented in the concluding plenary session. In this conference report, selected aspects of these discussions are presented. The insights gained are to be incorporated into the "DART 2030" strategy., (© 2022. The Author(s).)

The collection of data on SARS-CoV‑2 tests is central to the assessment of the infection rate in the context of the COVID-19 pandemic. At the Robert Koch Institute (RKI), data collected from various laboratory data recording systems are consolidated. First, this article aims to exemplify significant aspects regarding test procedures. Subsequently the different systems for recording laboratory tests are described and test numbers from the RKI test laboratory query and the laboratory-based SARS-CoV‑2 surveillance as well as accounting data from the Association of Statutory Health Insurance Physicians for SARS-CoV‑2 laboratory tests are shown.Early in the pandemic, the RKI test laboratory query and the laboratory-based SARS-CoV‑2 surveillance became available and able to evaluate data on performed tests and test capacities. By recording the positive and negative test results, statements about the total number of tests and the proportion of positive test rates can be made. While the aggregate test numbers are largely representative nationwide, they are not always representative at the state and district level. The billing data of the Association of Statutory Health Insurance Physicians can complement the laboratory data afterwards. In addition, it can provide a retrospective assessment of the total number of SARS-CoV‑2 numbers in Germany, because the services provided by statutory health insurers (around 85% of the population in Germany) are included. The various laboratory data recording systems complement one another and the evaluations flow into the recommended measures for the pandemic response.

When the emerging novel SARS-CoV‑2 virus first appeared in December 2019, neither specific therapeutic options nor vaccinations were available. The role of nonpharmaceutical interventions (NPIs) became of central importance. At the Robert Koch Institute, a multilayer strategy consisting of population-based and individual preventive measures to control the pandemic was developed, which built upon existing influenza pandemic plans as well as generic plans. This paper explains the recommended NPIs and illustrates the pharmaceutical approaches developed in parallel.Among others, general contact bans, providing material for infection prevention and control, ban of events, closing educational institutions, and restricting travel are counted among population-based measures. Additional individual preventive measures are necessary, e.g., keeping a minimum distance, reducing contacts, and wearing a mouth-nose covering as well as quarantine and isolation. Measures within the health system are based on recommendations of the Commission on Hospital Hygiene and Infection Protection (Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO)) and specified and implemented by professional societies. Since November 2020, an antiviral therapy with remdesivir and treatment with the glucocorticoid dexamethasone have been available as pharmaceutical interventions. Monoclonal antibodies are at this time not approved. Therapeutic anticoagulation is recommended.Recommendations are constantly adapted to the increasing knowledge on the pathogen and its means of transmission. A challenge is to strengthen the trust of the population. Many measures have to be applied on an individual basis in order to work together.

Germany's position on prescribing antibiotics is among the lower third in Europe. There are some countries that prescribe remarkably fewer antibiotics. In Germany, the number of out-patient antibiotic prescriptions is too high for patients with low-grade infections and non-bacterial infections. Often, broad-spectrum antibiotics are prescribed instead of narrow-spectrum antibiotics. For in-patients, perioperative prophylaxis is given for too long.In this article, different ways to reduce antibiotic prescriptions are introduced. Recommendations are given to improve the quality of therapy, implementation of diagnostics and scores, as well as information for physicians and patients.In this regard, an unsystematic literature search was done.To optimise the quality of prescribing, antibiotic checklists should be used. The important initial questions are if there is a bacterial infection and if antibiotic therapy is necessary. To apply diagnostics correctly is essential. Antibiotic use can be shortened or in some cases totally omitted if point-of-care tests (POCTs) are applied correctly. Species identification and resistance testing are essential for quality assurance. S3-guidelines are central for modern evidence-based medicine. Another key factor is good communication within the team and with patients. All measurements, like the application of POCTs, back-up prescribing, and prescribing an antibiotic, have to be communicated in a clear and sensitive way.

Background: In addition to acute care hospitals, rehabilitation centres are increasingly confronted with multi-resistant pathogens. Long durations of stay and intensive treatments impose special hygienic challenges., Material and Methods: We investigated an extended spectrum beta-lactamase-Klebsiella pneumoniae (ESBL-K. pneumoniae) outbreak in a neurorehabilitation centre. We defined confirmed cases as patients who stayed in the centre during the outbreak period and from whom ESBL-K. pneumoniae was isolated with the outbreak sequence type. Probable cases had an epidemiological link to at least one confirmed case but no isolate for typing. Next generation sequencing (NGS) was performed on 53 isolates from patients. Environmental sampling was performed. Systematic microbiological screening was implemented and ESBL-K. pneumoniae-positive patients were cohorted in a designated ward., Results: We identified 30 confirmed and 6 probable cases. NGS revealed three genetic clusters: Cluster 1 - the outbreak cluster - with isolates of 30 cases (sequence type ST15), Cluster 2 with 7 patients (ST405) and Cluster 3 with 8 patients (ST414). In two patients, the outbreak strain developed further antibiotic resistance, one with colistin resistance and the other carbapenem resistance. The outbreak ceased after strict isolation measures., Discussion: Epidemiology and NGS results paired with the effectiveness of cohorting suggest that transmission occurred mainly from person to person in this outbreak. There was an apparent association of the probability to acquire ESBL-K. pneumoniae and treatment intensity, whereas infection rate was related to morbidity. The identification of the outbreak clone and additional clusters plus the development of additional antibiotic resistance shows the relevance of NGS and highlights the need for timely and efficient outbreak management.

Antimicrobial resistance (AMR) is increasingly perceived as a global health problem. To tackle AMR effectively, a multisectoral one health approach is needed. We present some of the initiatives and activities at the national and global level that target the AMR challenge. The Global Action Plan on AMR, which has been developed by the World Health Organization (WHO), in close collaboration with the Food and Agriculture Organization of the United Nations (FAO) and the World Organisation for Animal Health (OIE) is considered a blueprint to combat AMR. Member states endorsed the action plan during the World Health Assembly 2015 and committed themselves to develop national action plans on AMR. The German Antibiotic Resistance Strategy (DART 2020) is based on the main objectives of the global action plan and was revised and published in 2015. Several examples of the implementation of DART 2020 are outlined here.

According to the German Protection Against Infection Act (IfSG; section 23 paragraph 4, July 2011), hospitals and clinics for ambulatory surgery are obliged to establish a continuous monitoring of antibiotic consumption in their institute. The introduction of the surveillance of antibiotic consumption aims to contribute to an optimization of antibiotic prescription practices in order to confine the development and spread of resistant pathogens. The local public health authority is entitled to supervise the implementation of legal requirements in the hospital setting. The main aim of this article is to support local public health authorities in coping with this task by providing background information on the surveillance of antibiotic consumption and its role as a key component of antibiotic stewardship programs. Furthermore, criteria suitable for assessing the implementation of a functioning surveillance system are proposed. The possibilities and limitations of the activities of public health authorities in this context are addressed.

The presence of pathogenic bacteria with acquired carbapenem resistance constitutes an increasing problem for infection control and infectious disease management. Prompted by an outbreak of infections with Klebsiella pneumoniae producing the carbapenemase KPC-2 at a hospital in Saxony, the Saxon State Ministry of Social Affairs and Consumer Protection (SMS) initiated a point-prevalence survey for carbapenemase-producing gram-negative bacteria. Wards at 53 hospitals in Saxony, mainly intensive care units, were investigated between October 2012 and February 2013. Stool samples and rectal swabs of 1,037 patients were analyzed for the presence of bacteria with resistance against four major groups of antibiotics (4MRGN). Carbapenemase producers were detected in 3 patients [0.3% CI95 (0.0596; 0.843)] and carbapenem-resistant bacteria without carbapenemases were detected in 9 patients [0.9% CI95 (0.397; 1.64)]. Furthermore, antimicrobial susceptibility testing revealed 166 patients [16.0% CI95 (13.82; 18.38)] with extended-spectrum beta-lactamase (ESBL)-producing bacteria. At the time of investigation, K. pneumoniae producing the carbapenemase KPC-2 was diagnosed in 2 patients at one hospital. Moreover, it is necessary to remain vigilant towards other types of carbapenemase producers, as demonstrated by the finding of a Pseudomonas aeruginosa strain harbouring the carbapenemase VIM-1 in another hospital.

According to § 23 paragraph 4 of the German Infection Prevention Act (IfSG; July 2011), hospitals and clinics for ambulatory surgery are obliged to establish a continuous monitoring system of antibiotic consumption. This is aimed at contributing to an optimization of antibiotic prescription practices in order to confine the development and spread of resistant pathogens. The general requirements (restricted to hospitals) on the method and extent of data collection are provided by the national public health institution after discussion with representatives of various professional societies (Robert Koch-Institut, Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 59, 2013). The article aims to clarify these specifications and to provide background details. In agreement with national and European surveillance systems, the Anatomical Therapeutic Chemical (ATC)/Defined Daily Dose (DDD) classification system recommended by the WHO should be used as reference standard. Antibiotic consumption should be expressed as the number of DDDs per 100 patient days and per 100 admissions. The categories of antimicrobials and hospital organizational units to be monitored and the time intervals in which analyses should be conducted are determined. Furthermore, various approaches of data assessment are described.

In 2007, the Robert Koch Institute established the infrastructure for the national Antimicrobial Resistance Surveillance (ARS) system. Laboratories submit data of routine susceptibility testing of clinical samples from hospitals as well as from outpatient care settings in a standardized format to the Robert Koch Institute for central processing. The database for the period 2008-2011 comprises data of about 1.3 million samples from patients in hospital care and almost 800,000 samples from outpatients. Based on SIR interpretations of susceptibility, the trends of methicillin resistance of Staphylococcus aureus (MRSA) and cefotaxime non-susceptibility as an indicator of extended-spectrum beta-lactamases (ESBL) of Escherichia coli and Klebsiella pneumoniae were analyzed for four care settings or categories: hospital care, outpatient care, intensive care units, and isolates from blood cultures. After constant high levels of above 20%, the proportion of MRSA isolates showed a decline for the first time from 2010 to 2011 in hospital care overall, in intensive care units as well as in blood cultures; in outpatient care, MRSA proportions of about 13% were observed. Within the observed period, non-susceptibility to cefotaxime as an indicator of ESBL in E. coli showed an increasing trend in hospital care at a level above 10% in intensive care units, while cefotaxime non-susceptibility in K. pneumoniae was more frequent but without any trend. In outpatient care, the proportions of cefotaxime non-susceptibility increased year by year in both species resulting in nearly a doubling to 6%.

Data from the German Antibiotic Resistance Surveillance system (ARS) and statutory notification of methicillin-resistant Staphylococcus aureus (MRSA) in blood cultures are presented. ARS is a voluntary laboratory-based surveillance system providing resistance data of all clinical pathogens and sample types from hospitals and ambulatory care. Statutory notification includes MRSA detected in blood and cerebrospinal fluid by microbiological laboratories. Resistance data from 2008 to 2010 and MRSA-bacteraemia incidences from 2010 are presented. From 2008 to 2010, resistance data from 70,935 Staphylococcus aureus isolates were transferred to the national health institution. MRSA proportions in hospitals and outpatient care account for 19.2% and 10.6%, respectively. In hospital care high proportions of MRSA were found in nephrological, geriatric, neurological general wards and surgical ICUs (49.4%, 45.8%, 34.2%, and 27.0%, respectively), while in community outpatient care urological practices (29.2%) account for the highest values. In both healthcare settings urinary tract samples stand out with high proportions of MRSA (hospitals, 32.9%; outpatients, 20.5%). In 2010, 3900 cases of MRSA bacteraemia were reported, accounting for an incidence of MRSA bacteraemia of 4.8/100,000 inhabitants/year. Stratification by federal states shows considerable regional differences (range, 1.0-8.3/100,000 inhabitants/year). Vulnerable areas in hospitals and outpatient care have been pointed out as subjects for further inquiries.

Public health threats are increasingly triggered by events which span across international, national and state level jurisdictions. Innovative surveillance methods are needed to ensure adequate and timely response to such threats. In January 2009 the Department of Infectious Disease Epidemiology at the Robert Koch Institute (RKI) established a system of weekly telephone conferences with all competent authorities of the German federal states to identify, discuss and respond to infectious disease events in real-time. A regular and structured platform was developed for use between participants from state level public health authorities, the military and the RKI. During the first three quarters, 46 infectious diseases were covered, including mandatory reports of measles and meningococcal meningitis and outbreaks of cowpox, which does not have to be notified in Germany. Results of a targeted evaluation and a consistently high attendance rate both indicate that the teleconference has met additional needs for supplemental information exchange among participants. The telephone conference has proven to be a useful resource for rapid and direct communication, coordination and evaluation of signals for public health events in Germany.

The International Health Regulations (IHR 2005) are a legally binding agreement that was adopted by all WHO Member States and which entered into force in June 2007. While taking the challenges of a globalized world into consideration, the purpose of the IHR (2005) is to provide a framework for international efforts to contain or reduce the risk from public health threats that may spread between countries. To this end, the IHR (2005) contain rights and obligations for the States and for WHO concerning national and international surveillance, assessment and public health response. With respect to surveillance, States are required to notify WHO of all events "that may constitute a public health emergency of international concern" according to agreed criteria. This obligation applies to novel or evolving public health risks, taking into account the context in which the event occurs. The IHR (2005) also contain obligations regarding global preparedness to address public health threats which include the establishment of national capacity to both detect and respond to events by June 2012.

The revised case definitions established by the Robert Koch Institute will become effective on 1 January 2007. The case definitions provide criteria for the reporting of mandatory notifiable infectious diseases according to the German infectious disease control act. The new case definitions take into account recent developments in laboratory methods. Furthermore in the new edition the criteria were updated and clarified if necessary. For each case definition a paragraph 'reference definition' is introduced and explained. If applicable additional information (e.g., vaccination history) to be reported was added. In this article, the major changes of the revised case definitions are described.