Antimicrobial resistance emergence during war: looking for answers beyond antibiotics

Antimicrobial resistance (AMR) is one of the top 10 global public health threats facing humanity.¹ An estimated 4.71 million deaths were associated with bacterial AMR in 2021—this is predicted to rise to 8.22 million deaths in 2050.² Uren et al highlight the critical contribution of modern war and war-wounded casualties to the rise of multidrug-resistant organisms (MDROs)³. Contributing factors include explosive injuries often contaminated with soil and environmental debris, prolonged evacuation, and limited opportunities for early decontamination, facilitating difficult-to-treat infections to emerge.

AMR disproportionately affects low- and middle-income countries and fragile health systems.¹ The role of human conflict in the development of MDROs has been well described, most recently in relation to Ukraine and Palestine.^{4 5} War and natural disasters result in populations with significant medical needs being forced to travel, which has contributed to the international spread of MDROs.⁶ Infectious diseases know no borders; AMR needs to be viewed from a global perspective. The challenges faced by one healthcare system on the frontlines of armed conflict are relevant to us all.

This paper is a call to action and attention. The increasing prevalence of AMR requires us to look beyond antibiotics—there is no significant pipeline of novel antibiotics coming to market. Implementation of basic infection prevention and control, and antimicrobial stewardship, in this setting is critical. In addition, leveraging pre-existing systems, such as chemical, biological, radiological, and nuclear (CBRN) inspired decontamination principles, to trauma care should facilitate early recognition and prevention of MDRO emergence. Adequate water, sanitation, and hygiene infrastructure is essential to the proposed decontamination approach, relying on potable water for initial wound cleaning.³ Early wound irrigation, surgical debridement, and source control remain cornerstones of preventing wound infection.⁷ The authors propose to study the impact and feasibility of an adapted CBRN using two real-world operational cohort groups - with a plan to incorporate clinically meaningful evaluation metrics. This would, no doubt, make a meaningful contribution to this field of science and infection prevention. Tackling AMR requires multidisciplinary action and benefits from new pragmatic ways of thinking about our approach to infection. We will follow this work with great interest; studies to inform how best to implement infection prevention into practice in these challenging scenarios are needed.