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Background: The urinary microbiome, or urobiome, is a novel area of research that has been gaining attention recently, as urine was thought to be sterile for years. There is limited information about the composition of the urobiome in health and disease. The urobiome may be affected by several factors and diseases such as diabetes, a disease that often leads to kidney damage. Thus, we need to understand the role of the urobiome to assess and monitor kidney disease related to diabetes over time., Methods: We conducted a systematic review to summarize knowledge about the urobiome in association with diabetes mellitus and diabetic kidney disease. The search was conducted in several electronic databases until November 2024., Results: Eighteen studies were selected including cross-sectional case-control studies, cross-sectional surveys and one prospective longitudinal study. In total, the urobiome of 1,571 people was sequenced, of which 662 people had diabetes, and of these 36 had confirmed diabetic kidney disease; 609 were healthy individuals, 179 had prediabetes or were at risk of type 2 diabetes mellitus and 121 did not have diabetes but had other comorbidities. Eight studies analysed data from females, one was focused on male data, and the other nine had mixed female-male data. Most of the studies had a small sample size, used voided midstream urine, and used 16S rRNA sequencing., Conclusion: This systematic review summarizes trends seen throughout published data available to have a first baseline knowledge of the urinary microbiome, and its microbiota, in association with diabetes including the decreased richness and α-diversity in urinary microbiota in individuals with diabetes compared to healthy controls and the decreased α-diversity with the evolution of kidney disease independently of the cause., Competing Interests: J.Ä. has served on the advisory boards for Astella, AstraZeneca, and Boehringer Ingelheim and has received lecturing fees from AstraZeneca and Novartis, all unrelated to the present work. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The remaining authors declare no competing interests. There are no patents, products in development or marketed products associated with this research to declare., (Copyright: © 2025 Graells et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Antimicrobial Resistance (AMR) is a global problem with large health and economic consequences. Current gaps in quantitative data are a major limitation for creating models intended to simulate the drivers of AMR. As an intermediate step, expert knowledge and opinion could be utilized to fill gaps in knowledge for areas of the system where quantitative data does not yet exist or are hard to quantify. Therefore, the objective of this study was to identify quantifiable data about the current state of the factors that drive AMR and the strengths and directions of relationships between the factors from statements made by a group of experts from the One Health system that drives AMR development and transmission in a European context., Methods: This study builds upon previous work that developed a causal loop diagram of AMR using input from two workshops conducted in 2019 in Sweden with experts within the European food system context. A secondary analysis of the workshop transcripts was conducted to identify semi-quantitative data to parameterize drivers in a model of AMR., Main Findings: Participants spoke about AMR by combining their personal experiences with professional expertise within their fields. The analysis of participants' statements provided semi-quantitative data that can help inform a future of AMR emergence and transmission based on a causal loop diagram of AMR in a Swedish One Health system context., Conclusion: Using transcripts of a workshop including participants with diverse expertise across the system that drives AMR, we gained invaluable insight into the past, current, and potential future states of the major drivers of AMR, particularly where quantitative data are lacking., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: EN, TG, and DW have no declarations of interest to report. MC and IAL work for the Public Health Agency of Canada. EJP is engaged in research funded by the Canadian Institutes for Health Research, Natural Sciences and Engineering Research Council, Ontario Ministry of Agriculture, Food and Rural Affairs, the Public Health Agency of Canada, and the Canadian Safety and Security Program. She is currently President of the Board of Directors of the Centre for Coastal Health, president of the Canadian Association of Veterinary Epidemiology and Preventive Medicine, member of the Board of Directors of the McEachran Institute, member of the Advisory Council for Research Directions: One Health, and a member of the Royal Society of Canada One Health Working Group. Prior to February 2019, she was employed by the Public Health Agency of Canada. ALG is engaged in research funded by the Canadian Institutes for Health Research, Natural Sciences and Engineering Research Council, Agriculture Canada, and Canada First Research Excellence Fund. She has served as a consultant for the Ontario Secondary School Teachers Federation (OSSTF) and as an expert witness in legal proceedings related to the SARS-CoV-2 pandemic. She is currently a member of the Board of Directors for the NSERC Emerging Infectious Disease Modelling Network – OMNI network, and Advisory Board Member of the National Collaborating Centre for Infectious Diseases (NCCID). Prior to January 2014, she was employed by the Public Health Agency of Canada. PJGH is partially funded by FORMAS Inequality and the Biosphere Project (2020-00454) and partially by CGIAR Trust Fund. PJGH is a member of the Technical Committee for the BAP Vanguard Climate Action Standard and PJGH and MT act as scientific advisors to the Seafood Business for Ocean Stewardship (SeaBOS) initiative. PJGH was supported by the CGIAR Research Program on Fish Agri-Food Systems (FISH) led by WorldFish and on Climate Change, Agriculture and Food Security (CCAFS) supported by contributors to the CGIAR Trust Fund. PJGH and MT acknowledge the Kjell and Märta Beijer Foundation for supporting this work through the Beijer Institute’s Aquaculture and Sustainable Seafood programme, and the SEAWIN project funded by FORMAS (2016-00227). PJGH is partially funded by FORMAS Inequality and the Biosphere project (2020-00454). AL works for the Swiss Federal Food Safety and Veterinary Office. PSJ was also funded via an ERC starting grant: INFLUX, grant number 101039376. He holds/has held grants as principal or co-investigator, from the following agencies and foundations all related to the topics of social-ecological systems and/or AMR: Swedish Research Council FORMAS, Wallenberg Foundations, IKEA Foundation, Erling Persson Family Foundation. CAC works for Government of Canada at the Public Health Agency of Canada. In that role she has been a subject matter expert for the World Organisation for Animal Health (WOAH) and the World Health Organization (WHO). She is a member of the advisory committee for Animal Health Canada. She has previously been engaged in research funded by the Canadian Institutes for Health Research, Ontario Ministry of Agriculture, Food and Rural Affairs, and the Canadian Safety and Security Program and has been a co-topic editor for two volumes of a Frontiers in Veterinary Science, Research Topic: Antimicrobial Usage in Companion and Food Animals: Methods, Surveys and Relationships with Antimicrobial Resistance in Animals and Humans. SEM is (or has been in the last 5 years) engaged in research grants/contracts funded by the Canadian Institutes for Health Research, the Bill and Melinda Gates Foundation/UK Dept., International Development, the Natural Sciences and Engineering Research Council of Canada, Institut de recherche Robert-Sauvé en santé et en sécurité du travail, Dairy Farmers of Canada Research Funding Program, the World Health Organization, British Columbia Centre for Disease Control, Indian and Northern Affairs Canada, and Ontario Ministry of Agriculture, Food and Rural Affairs. She currently sits on the Editorial Boards of Foodborne Pathogens and Disease, and Epidemiology and Infection, and is a member of the World Health Organization’s Foodborne Disease Burden Epidemiology Reference Group, and she has served as a paid expert on behalf of the Attorney General of Canada in legal proceedings, providing evidence on the public health risks and benefits of unpasteurized milk. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Cousins et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Antimicrobial resistance (AMR) is a global crisis that evolves from a complex system of factors. Understanding what factors interact is key to finding solutions. Our objective was to identify the factors influencing AMR in the European food system and places to intervene., Materials and Methods: We conducted two workshops involving participants with diverse perspectives to identify the factors influencing AMR and leverage points (places) to target interventions. Transcripts were open coded for factors and connections, then transcribed into Vensim 8.0.4 to develop a causal loop diagram (CLD) and compute the number of feedback loops. Thematic analysis followed to describe AMR dynamics in Europe's food system and places for intervention. The CLD and themes were confirmed via participant feedback., Results: Seventeen participants representing human, animal and agricultural sectors identified 91 CLD factors and 331 connections. Seven themes (e.g., social and economic conditions) describing AMR dynamics in Europe's food system, five 'overarching factors' that impact the entire CLD system (e.g., leadership) and fourteen places for intervention (e.g., consumer demand) emerged from workshop discussions. Most leverage points fell on highly networked feedback loops suggesting that intervening at these places may create unpredictable consequences., Conclusions: Our study produced a CLD of factors influencing AMR in Europe's food system that implicates sectors across the One Health spectrum. The high connectivity between the CLD factors described by participants and our finding that factors are connected with many feedback mechanisms underscores the complexity of the AMR problem and the challenge with finding long-term solutions. Identifying factors and feedbacks helped identify relevant leverage points in the system. Some actions, such as government's setting AMU standards may be easier to implement. These actions in turn can support multi-pronged actions that can help redefine the vision, values and goals of the system to sustainably tackle AMR., Competing Interests: I.A.L., M.C., T.G., A.L., S.H., D.W., P.S.J., and E.J.P. have no competing interests to declare. P.H. is a member of the Technical Committee for the BAP Vanguard Climate Action Standard and P.H. and M.T. act as scientific advisors to the Seafood Business for Ocean Stewardship (SeaBOS) initiative. P.H. was supported by the CGIAR Research Program on Fish Agri-Food Systems (FISH) led by WorldFish and on Climate Change, Agriculture and Food Security (CCAFS) supported by contributors to the CGIAR Trust Fund. P.H. and M.T. acknowledge the Kjell and Märta Beijer Foundation for supporting this work through the Beijer Institute’s Aquaculture and Sustainable Seafood programme, and the SEAWIN project funded by FORMAS (2016-00227). P.H. is partially funded by FORMAS Inequality and the Biosphere project (2020-00454). A.P.D. is (or has been in the last 5 years) engaged in research grants funded by the Sustainable Aquaculture Innovation Centre, UK Research and Innovation, International Veterinary Vaccinology Network, Scottish Funding Council, Great British Prawns Ltd and Benchmark Animal Health. C.A.C. works for the Government of Canada at the Public Health Agency of Canada. C.A.C. is/has been a subject matter expert for the World Organisation for Animal Health (OIE) and the World Health Organization (WHO) and has been a co-topic editor for two volumes of a Frontiers in Veterinary Science, Research Topic: Antimicrobial Usage in Companion and Food Animals: Methods, Surveys and Relationships with Antimicrobial Resistance in Animals and Humans. S.E.M. is (or has been in the last 5 years) engaged in research grants/contracts funded by the Canadian Institutes for Health Research, the Bill and Melinda Gates Foundation/UK Dept., International Development, the Natural Sciences and Engineering Research Council of Canada, Institut de recherche Robert-Sauvé en santé et en sécurité du travail, Dairy Farmers of Canada Research Funding Program, the World Health Organization, British Columbia Centre for Disease Control, Indian and Northern Affairs Canada, and Ontario Ministry of Agriculture, Food and Rural Affairs. She currently sits on the Editorial Boards of Foodborne Pathogens and Disease, and Epidemiology and Infection, and is a member of the World Health Organization’s Foodborne Disease Burden Epidemiology Reference Group, and she has served as a paid expert on behalf of the Attorney General of Canada in legal proceedings, providing evidence on the public health risks and benefits of unpasteurized milk. This does not alter our adherence to PLOS ONE policies on sharing data and materials.