Tropical Medical Microbiology in Transition

Technological Advancements, Artificial Intelligence, Epidemiological Shifts, and Military Medical Implications

Hagen Frickmann^a

^a Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg

Summary

In addition to clinical disciplines, infectious disease diagnostics is also an aspect of the management of tropical diseases. For 20 years, the Bundeswehr Hospital Hamburg has cooperated with the Bernhard Nocht Institute for Tropical Medicine Hamburg, the National Reference Centre for Tropical Infectious Diseases, including in microbiology. As a narrative overview, this article illustrates how tropical infectious disease diagnostics is undergoing contemporary methodological adaptations and innovations of interest to military medicine, using malaria, a disease typically associated with tropical medicine, as an example. Epidemiological shifts over the past decades in the subtropics and tropics are summarised, with a focus on the increasing importance of antimicrobial resistance, including in resource-limited deployment settings.

Traditionally, the diagnosis of malaria has been a domain of microscopy. Beginning around the turn of the millennium, molecular malaria diagnostic approaches have gained increasing importance, particularly in non-endemic areas, and now represent a genuine alternative as emergency diagnostics, alongside other indications. Furthermore, AI-supported (artificial intelligence) pattern recognition algorithms are increasingly adopted via fully automated microscopy and automated malaria diagnostics in haematological cell counters.

Since the first applications of sulfonamide-based antibiotics during World War II, military medicine has faced the problem of increasing antimicrobial resistance. However, it was just the episode of interventional deployments in subtropical Iraq and Afghanistan at the beginning of the millennium that highlighted a quantitatively new and substantial dimension of the issue for military medicine.

Tropical microbiology is subject to constant development and advancement, requiring continuous adaptation to both technological innovations and shifts in epidemiological priorities. Cooperation helps to identify and implement military medical solutions adapted to these challenges and to the most up-to-date developments in microbiology.

Keywords: tropical medical microbiology; diagnostics; epidemiology; multidrug resistance; military medicine

Introduction

Tropical medical microbiology is a focus at the Bundeswehr Hospital Hamburg due to a cooperative agreement with the Bernhard Nocht Institute for Tropical Medicine (BNITM) in Hamburg, home to the National Reference Centre for Tropical Infectious Diseases. Like diagnostic microbiology at large, which has undergone significant changes due to methodological advancements – such as the routine availability of molecular biology [61] and mass spectrometry [10]. Tropical medical microbiology is transitioning from highly examiner-dependent methods to more standardised and automated ones. This article aims to exemplify this transformation through malaria diagnostics, which is classically associated with tropical infectious disease medicine due to its clinical importance.

Pathways to Less Examiner-Dependent Malaria Diagnostics

The World Health Organisation (WHO) defines microscopy as the “gold standard” for malaria diagnostics, detailing the process involving the “thick drop” screening method and the fixed blood smear for fine differentiation in a comprehensive quality assurance manual [48]. The comparatively lower sensitivity of microscopy relative to diagnostic molecular biology – the probability of correctly identifying an existing malaria infection – is knowingly and justifiably accepted [2]. The microscopic detection limit for malaria is approximately 50 parasites per microliter of blood [17], while more sensitive molecular biology can detect so-called “submicroscopic infections” [2]. The WHO’s adherence to the less sensitive diagnostic method is nonetheless justifiable. On the one hand, very low parasite loads in the blood of semi-immune individuals in high-endemic malaria regions in the global south are not necessarily the cause when patients present with febrile symptoms. In such cases, molecular biology would frequently diagnose submicroscopic malaria. Still, an automatic and unreflected association with a febrile illness due to such a result would be a potentially patient-safety-endangering misjudgment. This would particularly apply if, upon detection of submicroscopic malaria in high-endemic areas, the search for also possible differential diagnoses was abandoned. On the other hand, microscopy, especially when not considering the personnel costs for the time-consuming examination by qualified specialists, is comparatively inexpensive regarding the required laboratory equipment and necessary consumables. This is health-economically relevant in resource-­limited regions, where often the costs of laboratory equipment and reagents are more limiting factors than personnel availability.

Immune-chromatographic rapid tests that detect circulating parasite antigens in the blood are resource-conserving but have inherent methodological limitations that can impact their interpretation. In particular, plasmodia that do not adequately express the diagnostically utilised “histidine-rich protein” can lead to interpretation difficulties and, in unfavourable cases, to false-negative results [55].

Unlike in high-endemic malaria regions, where semi-immunity plays a quantitatively significant role, every plasmodial infection is considered medically relevant in travel medicine. It should be diagnosed as early as possible. Although highly sensitive PCR (polymerase chain reaction) assays for epidemiological studies were described as early as at the beginning of the millennium [40], it took until the middle of the second decade for automation to advance to the point where the first European guidelines incorporated molecular biological rapid test systems based on PCR or LAMP (= loop-mediated isothermal nucleic acid amplification, a method of amplifying pathogen-specific nucleic acid sequences that, unlike PCR, does not require cyclic temperature changes) as equivalent to microscopy in screening workflows [50].

Recommendations for Molecular Malaria Diagnostics and Their Practical Implementation

The German malaria guideline and the recommendations of the German Society for Tropical Medicine, Travel Medicine, and Global Health (DTG) (current versions at the time of manuscript preparation [47][55]) also described the option of molecular biology as part of malaria diagnostics early on. Various guideline-recommended indications for molecular biological malaria diagnostics are shown in Table 1.

Tab. 1: Description of the Indications for Molecular Malaria Diagnostics According to the Current Guideline [47] and Its Predecessors.

In workflows at the Bundeswehr Hospital Hamburg, molecular malaria diagnostics, partly through assays evaluated jointly with BNITM, are implemented [13][14]. Molecular biology is used in an automated manner for the initial highly sensitive exclusion of malaria in emergency diagnostics [13][38] and subsequently to exclude parasitic mixed infections. In this indication, it surpasses microscopy [14]. Persistent weaknesses of molecular malaria diagnostics include the occasionally improvable concordance with microscopy regarding parasite quantification [14], which plays a role as a parameter in assessing infection severity or in therapy monitoring. However, it enables differentiation below the level of the Plasmodium ovale complex [15], which cannot be achieved by the naked eye using microscopy alone. Due to the lack of therapeutic consequences so far, such diagnostic depth in tertian malaria diagnostics is still considered academic and, logically, not required by the guidelines [47].

Fig. 1: Development of Malaria Diagnostics: From Classical Microscopy (left) to Molecular Diagnostics Using Real-time PCR (right) (Image Rights: H. Frickmann)

Artificial Intelligence as an Enabler for Further Improving Patient Safety

The third decade of this millennium also holds further automation potential in malaria diagnostics, this time related to the remarkable capabilities of artificial intelligence (AI) in image and pattern recognition. Recently, a malaria case diagnosed using fully automated, AI-evaluated microscopy was published by the University Hospital in Leipzig [26]. This is not merely experimental diagnostics. Corresponding machines, which are also small and thus potentially portable, have been evaluated so comprehensively [45] that they are already approved for in vitro diagnostics in the European Union.

The “downside” of this type of automation is that submitting clinical personnel must still consider malaria as a differential diagnosis for targeted automated microscopic diagnostics to be initiated. This issue has since been addressed by developers of haematological laboratory machines so that modern generations of machines can diagnose malaria “incidentally” during blood count analysis [50]. The detection limits of this modern generation of blood count machines are given in the range of expert microscopy [51]. Therefore, their application does not pose a disadvantage concerning the risk of missing malaria compared to the WHO-recommended standard microscopy. Malaria diagnostics through such blood count machine-supported “incidental findings” are now approved for in vitro diagnostics in the European Union and can be used in routine laboratories if laboratories or laboratory system networks do not shy away from the sometimes still considerable acquisition costs.

Given these dynamic developments, it remains to be seen how long the traditional WHO recommendations in the guidelines for malaria diagnostics [48] will remain valid. Today, it is emerging that AI algorithms are at least equivalent to the human eye in pattern recognition [66]. Therefore, it seems only a matter of time before human expertise in malaria diagnostics will focus more on the contextual interpretation of findings than on basic manual diagnosis confirmation.

Shift in Thematic Focuses in Tropical Infection Epidemiology

Especially those of us who are no longer so young and had the opportunity to participate in the three-month “large” tropical course at the BNITM one to two decades ago will remember the significant emphasis on the diagnostics of parasites in general and helminths (worms) in particular during knowledge transfer. However, the prevalence of such helminth infections in many tropical regions had already drastically declined quantitatively due to mass treatment programs in the first decade of this century [1]. While certain worm diseases such as bilharziosis and Strongyloides stercoralisinfections still occurred frequently among symptomatic and asymptomatic German military and police returnees from subtropical and tropical stabilisation missions in the first two decades of the millennium [18][60], other, sometimes clinically still inconspicuous health risks, like the carrier status with antibiotic-resistant microorganisms, already dominated [46]. This is exemplified in Table 2 for the enteric carrier status with the internationally frequently detected ESBL (extended-spectrum beta-lactamase) gene blaCTX-M. Recent modelling of expected resistance development by 2050 has been published in high-ranking journals [16], indicating that mortality risks from antimicrobial resistance will disproportionately affect resource-limited tropical regions. Therefore, antimicrobial resistance selection is not a “luxury problem” but a topic that military medicine must also address concerning deployments in resource-limited conflict areas of the global South.

„X/Y“ = X positive findings out of Y individuals examined, „(%)“ = percentage of positive findings, „-“ = no data available

Tab. 2: Detection of bla_CTX-M ESBL Genes in Stool Samples from Military and Police Deployment Returnees from Missions in Various WHO (World Health Organization) Regions. (Table adapted from [47])

Antibiotic Resistance in Military Medicine

According to the World Health Organisation [3], antimicrobial resistance is one of the greatest global health and development threats. Historically, the military and military deployments have significantly contributed to the acquisition, and importation of resistant microorganisms into soldiers’ home countries, as well their spread [24].

The relevance and urgency of the issue were recognised and addressed early on by the U.S. armed forces, based on their experiences from military engagements in the Middle East at the beginning of the millennium. One response to this challenge, more than 10 years ago, was the implementation of a large-scale, well-funded, network-based surveillance campaign to characterise further health risks associated with multidrug-resistant bacterial pathogens, conducted under the name “Antimicrobial Resistance Monitoring and Research Program” [8][67]. The U.S. military medical service established large-scale molecular epidemiological studies of resistant bacterial isolates based on next-generation sequencing (NGS) [35] early on.

Historical Overview of Antimicrobial Resistance ­Epidemiology in Armed Forces

The enormous effort the U.S. medical service invests in this field contrasts sharply with the optimistic view the U.S. military held regarding the potential of antibiotics in the early years of their development. A representative example of this is the ambitious approach of U.S. Medical Corps officers Captain James A. Loveless and Colonel William Denton to use the orally applicable sulfonamide derivative sulfathiazole prophylactically to counter the rapid spread of gonococci among U.S. forces during World War II. This approach was published in 1943 [37], shortly after Gerhard Domagk introduced the first widely available sulfonamide antibiotics as an antimicrobial class in the late 1930s.

However, this optimism did not last long. During the Vietnam War, the development of penicillin resistance in gonococcal isolates came into focus for the U.S. military medical service [22][62]. In the 1980s, resistance rates of Neisseria gonorrhoeae to penicillin, tetracycline, and cefoxitin increased so significantly in the military environment, even in the U.S. mainland, that the use of these drugs for the empirical treatment of gonorrhoea without antimicrobial resistance testing could no longer be generally recommended [52]. Nevertheless, Loveless and Denton’s hope to address gonorrhoea prophylactically without unpopular prohibitive prevention approaches remains relevant, as evidenced by the recent ANRS 174 DOXYVAC study on combined antibiotic and vaccine prevention [42].

However, antibiotic resistance that complicated the treatment of bacterial sexually transmitted infections was not the only resistance-associated challenge for the medical service. While the first reports of primary resistance in Mycobacterium tuberculosis appeared in military medical literature as early as the 1960s [32], significant resistance rates to first-line tuberculosis drugs were observed among immigrants working for the U.S. military in the 1970s [6]. In the 1980s, outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) were first reported from military medical facilities, as exemplified by a British Royal Navy hospital [4]. By 2016, the MRSA colonisation rate on U.S. Navy ships outside specific outbreak situations had risen to 3.5 % [11]. Additionally, between 2008 and 2010, non-nosocomially acquired MRSA isolates were repeatedly detected in U.S. military training units. The number of MRSA infections per 1,000 U.S. soldiers was reported to be between 27 and 32 at that time [31].

Antibiotic Resistance in Modern Military Conflicts and the Growing Importance of Resistant Gram-­Negative Bacteria

In modern military conflicts and civil wars, antimicrobial resistance (AMR) poses a constant challenge to the success of antimicrobial therapies in medical care. Furthermore, there is increasing evidence that crises related to armed conflicts promote the spread of AMR. For example, a carbapenem-resistant Klebsiella pneumoniae isolate of sequence type ST11 expressing the blaNDM-1 enzyme was first isolated from the wound of an injured patient during the Euromaidan unrest in Ukraine [23].

In contrast, real-time epidemiological resistance surveillance from modern conflict zones remains the exception, as only well-resourced medical services, such as in the U.S., have the costly diagnostic capabilities to tackle the resistance problem on a large scale [9]. Consequently, U.S. studies have shown that gram-negative bacteria have accounted for the largest share of AMR-associated infection complications in the wars in Iraq and Afghanistan since the beginning of the millennium [5]. Between 2005 and 2007, 2,242 wounded U.S. soldiers from Operation Iraqi Freedom and Operation Enduring Freedom were examined for AMR by the U.S. military medical service. MRSA, Klebsiella pneumoniae, and Acinetobacter spp. were identified as the three most frequently detected bacterial pathogens, with nosocomial infection rates of 2 %–4 % each [44].

Fig. 2: Gram-negative Rods Frequently Exhibit Multidrug Resistance to Antibiotics (Image: BwKrhs Hamburg/Dept. XXI)

As early as the beginning of the U.S. military operation in Iraq from 2003 to 2005, osteomyelitis, burns, and deep wound infections associated with the Acinetobacter baumannii complex [12] led to prolonged therapies. This was especially true in the case of carbapenem resistance, which was usually caused by the expression of carbapenemases encoded on the blaOXA-23 gene in local isolates [54]. The U.S. Trauma Infectious Disease Outcome Study [7], conducted from 2009 to 2014 on trauma-related injuries, classified gram-­negative rods as “multiresistant” if they displayed resistance to 3 or more antibiotic classes r expressed “extended-spectrum” β-lactamases (ESBL) or carbapenemases. In this study, 26 % (n = 245) of soldier trauma patients were classified as infected with “multiresistant” bacteria. Resistant Escherichia coli isolates quantitatively dominated, followed by isolates of the A. baumannii complex and the K. pneumoniae complex. Nosocomial transmission in medical facilities was identified as a relevant factor early on. At the same time, in very early wound infections, and thus shortly after the causative injury on Iraqi battlefields, susceptible wild-type bacteria were often detected. This was at least true for the early years of the regional U.S. mission [43].

Impact of Deployment-Related Infection with ­Resistant Bacteria on Home Countries

Despite deployment-related exposure and associated colonisation, which was also confirmed in regional U.S. health centres abroad [68], the prevalence of carbapenem resistance in wound infections among U.S. military personnel remained manageable during the first two decades of the millennium. A study conducted between 2009 and 2015, focusing on Enterobacterales, revealed that only 0.4 % (16 out of 4,090) of isolates from the wounds of U.S. soldiers were carbapenem-resistant, with Klebsiella aerogenes, theK. pneumoniae complex, and E. coli being detectable in descending order [41]. Another study from 2015 reported an incidence of carbapenem-resistant Enterobacteriaceae in U.S. military medical facilities of only 1 per 100,000 patient-years. In this study, selection due to the therapeutic use of fluoroquinolones, with concurrent fluoroquinolone resistance in the affected bacterial isolates, was identified as the most important risk factor for the selection of carbapenemase producers. In contrast, other factors were negligible in relation [34].

Even for the more frequently occurring ESBL-type beta-lactam resistance in Enterobacteriales, a longitudinal study in U.S. military hospitals on the U.S. mainland showed only a moderate increase from low baseline values, for example, for E. coli from 0.13 % to 1.0 % and for the K. pneumoniae complex from 1.0 % to 2.6 % between 2005 and 2010 [30]. Furthermore, the distribution of ESBL-expressing E. coli sequence types among U.S. military personnel essentially mirrored the distribution in other North American populations, with the sequence types ST10, ST131, and ST648 dominating in a surveillance conducted between 2007 and 2011 [39].

The Civilian Healthcare System Is Also Affected

Although such observations suggest that deployment-related exposure to resistant bacteria has, if at all, only a moderate impact on the further spread of antibiotic-resistant bacteria within the healthcare infrastructure of the home country, infection prevention and hygiene management in hospitals treating war-injured or refugee patients from crisis areas pose a significant challenge. In an exemplary study from 2017 on the prevalence of multidrug-resistant bacteria among civil war casualties from Libya transferred to a maximum care civilian hospital in Germany, bacteria with non-wild-type resistance profiles were observed in 60 % of the patients, with carbapenem-resistant gram-negative bacteria (37 %) quantitatively dominating over MRSA (16 %) [36]. Several other cross-sectional studies on bacterial resistance in war casualties from the civil wars in Libya and Syria [27][29][33][53] reached similar results.

Finally, the medical treatment of war-injured Ukrainian patients in connection with the Russian war of aggression in Ukraine from 2022 even led to a measurable shift in the distribution of carbapenemase genes in Gram-negative bacterial isolates submitted from German hospitals to the National Reference Centre for Gram-Negative Hospital Pathogens in Bochum [59]. This phenomenon, which can still be measured even in relatively distant Germany, reflects a notable increase in carbapenem resistance in war-torn Ukraine in recent years. While moderate carbapenem resistance rates were still described for gram-negative pathogens in Ukraine in the first decade of the millennium [25][66], there was a substantial increase in the high double-digit percentage range for important Enterobacteriales and non-fermenting gram-negative rods in the second and current third decades [28][56–58].

Consequences of the Increasing Antimicrobial Resistance Risk for Medical Services

The increasing significance of infections with antibiotic-resistant bacteria in connection with war and crisis scenarios, as depicted above, almost invariably necessitates consistent medical support through appropriate surveillance measures. In close collaboration with the microbiological lead laboratory of the Microbiology and Hospital Hygiene Department at the Bundeswehr Central Hospital Koblenz and the B/ Population Medical Microbiology Section located there, tropical medical microbiology has consequently been involved in various studies on deployment-associated resistance surveillance [19–21][51]. The existing forecasts for the expected resistance development in the global South [16] suggest that dealing with antimicrobial resistance in connection with potential deployments or training exercises in resource-limited tropical regions will not lose significance.

Summary and Outlook

“Tempus fugit,” and developments do not spare traditional fields such as tropical medical microbiology, whether regarding how diagnoses will be made in the future or concerning the thematic focuses it must address. Unfortunately, the rapid development with which the standardisation of malaria diagnostics, as exemplified above, is foreseeably progressing primarily affects infection diagnostic parameters that occur frequently enough for the industry to find corresponding development projects economically worthwhile. For rare infection parameters, however, it is emerging that strict regulatory requirements could lead to the disappearance of certified market-available assays [64], making such diagnostics more than ever before the domain of reference centres. This underscores the importance of close collaboration between military medicine and specialised reference centres, as has been successfully practised with BNITM for two decades, to continue to make timely and appropriate diagnoses and initiate targeted therapies for rare infectious diseases acquired during deployments or training exercises abroad in tropical regions.

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Manuscript Data

Citation

Frickmann H. Changes in Tropical Medical Microbiology: Technological Progress, Artificial Intelligence, Epidemiological Shifts, and Military Medical Implications. WMM. 2026;70(9E):3.

DOI: https://doi.org/10.48701/opus4-966

Author

Lieutenant Colonel (MC) Prof. Dr. Hagen Frickmann

Department of Microbiology and Hospital Hygiene

Bundeswehr Hospital Hamburg

Lesserstraße 180, D-22049 Hamburg

E-Mail: hagenfrickmann@bundeswehr.org