Ukraine war and antimicrobial resistance.

Data on infections following war wounds during the current conflict in Ukraine have not yet been published; scant data are available on antimicrobial resistance among people with injuries. However, war wounds and antimicrobial resistance have been paired in the past two decades. The first cases of antimicrobial-resistant microorganisms reported in people with war wounds were described in military conflicts in Iraq and Afghanistan around 15 years ago.1Murray CK Yun HC Griffith ME et al.Recovery of multidrug-resistant bacteria from combat personnel evacuated from Iraq and Afghanistan at a single military treatment facility.Mil Med. 2009; 174598e604 Crossref Scopus (62) Google Scholar Eastern Ukraine has been involved in a conflict since 2014. Previous studies of hospital-acquired infections with multidrug-resistant bacteria were common in Ukraine before the 2022 invasion.2Salmanov A Shchehlov D Svyrydiuk O et al.Epidemiology of healthcare-associated infections and mechanisms of antimicrobial resistance of responsible pathogens in Ukraine: a multicentre study.J Hosp Infect. 2023; 131: 129-138Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar Antimicrobial resistance to third-generation cephalosporins was detected in 48·4% of all Enterobacterales. Antimicrobial resistance to carbapenems was detected in 71·3% of all non-fermentative Gram-negative bacteria (Acinetobacter spp, Burkholderia spp, and Stenotrophomonas maltophilia).2Salmanov A Shchehlov D Svyrydiuk O et al.Epidemiology of healthcare-associated infections and mechanisms of antimicrobial resistance of responsible pathogens in Ukraine: a multicentre study.J Hosp Infect. 2023; 131: 129-138Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar In the period from 2014 to 2020, the incidence of multidrug-resistant bacteria in war wounds in Ukraine was higher than that in Ukrainian civilian hospitals and other European countries.3Higgins PG Hagen RM Podbielski A Frickmann H Warnke P Molecular epidemiology of carbapenem-resistant Acinetobacter baumannii isolated from war-injured patients from the eastern Ukraine.Antibiotics (Basel). 2020; 9: 579Crossref PubMed Scopus (11) Google Scholar The detection of carbapenemase-producing Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae is of particular importance.4Kondratiuk V Jones BT Kovalchuk V et al.Phenotypic and genotypic characterization of antibiotic resistance in military hospital-associated bacteria from war injuries in the eastern Ukraine conflict between 2014 and 2020.J Hosp Infect. 2021; 112: 69-76Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 5Melwani M How war is spreading drug resistant superbugs across Ukraine and beyond.BMJ. 2022; 379o2731 PubMed Google Scholar In a retrospective, multicentre, microbiological survey in four Ukrainian military hospitals between 2014 and 2020, 813 organisms obtained from 1061 tests in 162 patients were analysed.5Melwani M How war is spreading drug resistant superbugs across Ukraine and beyond.BMJ. 2022; 379o2731 PubMed Google Scholar The predominant microorganisms were non-fermenting Gram-negative rods including Acinetobacter spp and P aeruginosa. Among 52 A baumannii microorganisms isolated, 37 (63%) were resistant to carbapenems.5Melwani M How war is spreading drug resistant superbugs across Ukraine and beyond.BMJ. 2022; 379o2731 PubMed Google Scholar Estimated numbers of killed or wounded soldiers in the conflict in Ukraine are controversial. According to the most senior US general, Mark Milley, by Nov 10, 2022, around 100 000 Russian soldiers and 100 000 Ukrainian soldiers had been killed or wounded since the start of the war.6BBC NewsUkraine war: US estimates 200,000 military casualties on all sides.https://www.bbc.co.uk/news/world-europe-63580372Date: Nov 10, 2022Date accessed: April 13, 2023Google Scholar Moreover, from Feb 24, 2022 (the start of the large-scale armed attack by the Russian Federation) to March 12, 2023, the Office of the High Commissioner for Human Rights recorded 21 965 civilian casualties in the country, with 8231 killed and 13 734 injured.7UN Office of the High Commissioner for Human RightsUkraine: civilian casualty update 13 March 2023.https://www.ohchr.org/en/news/2023/03/ukraine-civilian-casualty-update-13-march-2023Date: March 13, 2023Date accessed: April 13, 2023Google Scholar Currently, according to the deputy medical director for anaesthesiology and intensive care at St Nicholas Children's Hospital in Lviv, Ukraine, at least two-thirds of patients in this hospital had hospital-acquired and multidrug-resistant strains of bacteria as of Nov 22, 2022. Since March, 2022, the European Centers for Disease Control have advised that people with traumatic wounds in Ukraine might have multidrug-resistant A baumannii and K pneumoniae, among other multidrug-resistant organisms,8European Center for Disease ControlOperational public health considerations for the prevention and control of infectious diseases in the context of Russia's aggression towards Ukraine.https://www.ecdc.europa.eu/sites/default/files/documents/prevention-control-infectious-diseases-russia-aggression.pdfDate: March 8, 2022Date accessed: April 6, 2023Google Scholar and have recommended pre-emptive isolation and screening for carriage of multidrug-resistant bacteria (particularly carbapenem-restant Enterobacterales) for patients transferred from hospitals in Ukraine or with a history of hospital admission in Ukraine in the past 12 months. From March to June, 2022, Shultze and colleagues9Schultze T Hogardt M Velázquez ES et al.Molecular surveillance of multidrug-resistant Gram-negative bacteria in Ukrainian patients, Germany, March to June 2022.Euro Surveill. 2023; 282200850 Crossref PubMed Scopus (3) Google Scholar screened for multidrug-resistant Gram-negative bacteria in 103 Ukrainian patients at admission to the University Hospital Frankfurt, Germany. They found 34 multidrug-resistant Gram-negative isolates in 17 (17%) of 103 patients. The authors concluded that hospitals should consider infection control strategies to prevent the spread of hypervirulent carbapenem-resistant bacteria isolated when admitting patients from Ukraine, especially if they have war-related injuries.9Schultze T Hogardt M Velázquez ES et al.Molecular surveillance of multidrug-resistant Gram-negative bacteria in Ukrainian patients, Germany, March to June 2022.Euro Surveill. 2023; 282200850 Crossref PubMed Scopus (3) Google Scholar The war in Ukraine has devastated infrastructure and disrupted essential services, such as the provision of and access to energy, water, food, sanitation and hygiene, waste management, health care, education, housing, transport, and agricultural and industrial products.10Racioppi F Rutter H Nitzan D et al.The impact of war on the environment and health: implications for readiness, response, and recovery in Ukraine.Lancet. 2022; 400: 871-873Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar War-associated infection and antimicrobial resistance will have a dramatic impact on the health of people inside and outside the country, creating a vast reservoir of multidrug-resistant Gram-negative infections in Ukraine and Russia, with the potential for further spread. NP reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from MSD, Pfizer, Novartis, BD, Johnson & Johnson, GlaxoSmithKline, Novartis, Tillots, Thermo Fisher Scientific, and Roche; support from European Society for Clinical Microbiology and Infectious Diseases (ESCMID) to attend European Congress of Clinical Microbiology and Infectious Diseases (ECCMID); and is on the data safety monitoring board for ImmuneMed. EP reports payment from the University of Aarhus for lectures in Tropical Medicine; support from ESCMID to attend ECCMID; and holding stock or stock option for Ørsted and NovoNordisk. SA declares no competing interests.