A global enemy, invisible to the naked eye, is silently gaining ground on the battlefields of Ukraine. A group of German doctors has warned that bacteria have found fertile ground on the front lines of the war to develop new resistances to antibiotics and spread among the wounded and the field hospitals where they are treated. “The wounded often receive sub-optimal surgical and antibiotic treatment, in a context of lack of resources and in non-sterile conditions in war zones and emergency settings, sometimes for weeks or even months,” said internal medicine specialist Maria Virginia Dos Santos of the Charité-Berlin University of Medicine, one of the European institutions that has treated hundreds of war-wounded resulting from the Russian invasion of Ukraine.
The physicians have extensively analyzed multi-resistant infections found in the bones and soft tissues of 13 civilians and one soldier — six of them wounded by bullets and eight by grenade and bomb explosions — who were transferred to Germany for specialized treatment. The results have set alarm bells ringing. “The logistics of treatment in war, extensive wounds and infections with the additional problem of polymicrobial infections, caused by the combination of bacteria, fungi and parasites with multidrug-resistant pathogens, make these wounds extremely complex to treat,” Dos Santos said Tuesday at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in Copenhagen.
Since Moscow launched its invasion of Ukraine in February 2022, wounded civilians and soldiers who were initially stabilized in Ukrainian and Polish hospitals have been transferred to neighboring countries for further treatment. Between March and December last year, 47 patients from Ukraine were treated at the Musculoskeletal Surgery Center at the Charité-Berlin University of Medicine.
Of the 14 patients analyzed, 10 were men and four were women, including three minors, the youngest of whom was aged 14. The oldest was 64. Most infections were bone infections, followed by implant-associated infections, soft tissue infections and septic arthritis. The most common processes were in the lower extremities, but almost half of the patients had more than one anatomical area affected and two had multiple infected areas.
Of all the infections detected, 13 were due to multidrug resistant Gram-negative bacteria (MDRGN), mostly Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii and Escherichia coli, as well as other pathogens such as staphylococci, enterococci and fungi. Of the 25 Gram-negative bacterial isolates, nearly three-quarters (72%) were resistant to Carbapenems and the newer ceftazidime-avibactam and Ceftolozane/tazobactam antibiotics, which are used as a last resort used when the infection does not remit under treatment with other antibiotics. This is why these pathogens are often described as “superbugs.”
Among the isolates detected, 39% were resistant to the antibiotic cefiderocol, 20% to colistin and 96% to ciprofloxacin, one of the most widely used oral antibiotics. “We have encountered a completely new spectrum of pathogens for what is to be expected in Germany,” Dos Santos explained. “In these terrible war wounds, we are seeing a high incidence of multidrug-resistant Gram-negative pathogens, and in all cases, they have been polymicrobial infections. This means that we have had to adjust our previous antibiotic treatment strategies in order to cover these multidrug-resistant organisms.”
Of the 14 patients studied, 10 have been discharged but are still undergoing complex rehabilitation processes to regain mobility in limbs affected by war wounds and subsequent infections, as well as receiving treatment for the emotional impact suffered. The remaining four are still undergoing treatment; two have developed new acute infections.
The findings of the German physicians coincide with studies carried out in other conflict zones such as Iraq, where it had previously been observed that the conditions of war — a high number of wounded and scarce resources to treat them, which can result in the indiscriminate use of antibiotics that are not always appropriate — have produced high rates of bacterial resistance to antimicrobials, the negative impact of which on global health extends far beyond the battlefields.
Bacterial resistance to antibiotics kills more people worldwide today than HIV/AIDS and malaria combined, and it is estimated that by 2050, 12 million people will die every year due to super-bacteria. A study published by the European Centre for Disease Control and Prevention five years ago stated that in Europe alone, more than 33,000 people die each year as a result of superbugs.
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