Highly multidrug-resistant Gram-negative bacterial infections in war victims in Ukraine, 2022

The contribution of human conflict to the development of antimicrobial resistance

“…Prior to the outbreak of widespread conflict in 2022, Ukraine submitted surveillance data to the Central Asian and European Surveillance of AMR network that suggested increasing rates of MDRO ( https://apps.who.int/iris/rest/bitstreams/1496762/retrieve ; accessed 07 July 2023), particularly among military personnel and likely driven by injudicious antimicrobial use and limited capacity for IPC practices in management of casualties sustained since the annexation of areas of Ukraine by Russia in 2014 19 . Early, limited data suggests the eruption of widespread conflict has considerably exacerbated this issue 20 – 22 . The Netherlands national MDRO surveillance system has reported 58 patients with recent travel from Ukraine, of which half had recent hospital exposure in Ukraine prior to travel, in striking contrast to their pre-war experience where no MDROs associated with Ukrainian travel had been detected 20 .…”

“…Sentinel testing (random testing to provide data that is potentially representative of the targeted condition at the hospital level) of hospitalised individuals with infected, war-related injuries in Ukraine during 2022 revealed most Gram negative isolates were resistant to the antibiotic meropenem (58%), with K. pneumoniae (76%) and A. baumanii (73%) producing NDM and OXA-48 carbapenemase enzymes predominating 22 . Of concern, nine (all K.pneumoniae ) were resistant to all antimicrobials tested 21 .…”

“…Of concern, nine (all K.pneumoniae ) were resistant to all antimicrobials tested 21 . Extended AST demonstrated high rates of resistance to a range of β-lactam β-lactamase inhibitor combinations (often last line antibiotic options for MDROs), including ceftazidime-avibactam, as well as cefiderocol 22 . Clinical outcome data for treating war-related infected injuries is severely limited, but such reports will be important to identify the most suitable antimicrobials for post-injury and peri-operative guidelines 23 .…”

“…Example 1 (red; Ukraine), the proportion of AMR microbes isolated from patients with infections of war-related injuries increased considerably in 2022 compared to 2021. Data was obtained from nationally collected surveillance data (2021; https://apps.who.int/iris/rest/bitstreams/1496762/retrieve ; accessed 07 July 2023) and EUCAST supported sentinel susceptibility testing (2022) 22 in the context of eruption of major widespread conflict in March 2022 Example 2 (green, Syrian Arab Republic) highlights that availability of antibiotics decreased during the conflict which led to a critical shortage and loss of drug supply security 17 , 18 . Example 3 (blue; Afghanistan) highlights molecular typing research that showed potential chains of transmission of AMR spread to the destination countries 19 .…”

Notes from the Field: Responding to the Wartime Spread of Antimicrobial-Resistant Organisms — Ukraine, 2022

“…Worldwide, bacterial antimicrobial resistance is estimated to cause more deaths than HIV or malaria and is recognized as a leading global public health threat ( 1 ). In Ukraine, the confluence of high prewar rates of antimicrobial resistance, an increase in the prevalence of traumatic wounds, and the war-related strain on health care facilities is leading to increased detection of multidrug-resistant organisms with spread into Europe ( 2 , 3 ). Evidence of increased rates of antimicrobial resistance in other conflict settings such as Iraq ( 4 ), and the long-term consequences for civilian, military, and other populations, argue that the spread of antimicrobial resistance in Ukraine is an urgent crisis that must be addressed, even during an ongoing war.…”