Russia’s invasion of Ukraine is fueling a dangerous rise in bacterial drug resistance—an alarming reality made clear by a recent case report of an injured Ukrainian soldier who became infected with six different extensively drug-resistant bacteria, one of which was resistant to every antibiotic tested.
Health experts are sounding the alarm that the nearly unbeatable germs will likely spread beyond the war-torn country’s borders. “Given the forced migration of the population, multidrug resistance of wound pathogens is now a problem not only for Ukraine but also for healthcare systems around the world, especially in the EU,” Ukrainian scientists and doctors wrote in a recent letter in the Irish Journal of Medical Scientists.
The rise of antibiotic resistance is a long-standing, critical threat to global public health. In 2019, antimicrobial resistance was directly responsible for an estimated 1.27 million deaths worldwide and linked to an estimated 4.95 million total, according to an analysis published last year in the Lancet.
But the chaos and tragedies of war can exacerbate and accelerate the crisis by creating ideal conditions for antimicrobial resistance to mount an incursion. War causes severe and complex types of wounds, which are often contaminated with environmental bacteria, dust, soil, and metals from explosives. Toxic metals can help spur bacteria to develop, select for, and share genetic determinants of drug resistance. And the dirty wounds create an eclectic milieu of different types of microbes for wider drug resistance sharing.
The injured, meanwhile, often encounter broken and extremely strained health care systems, where proper infection control measures are impossible, and laboratory testing to inform treatment for bacterial infections is unavailable. Broad-spectrum antibiotics are often handed out readily to keep people alive as they’re evacuated, which sometimes involves moving through a chain of health care facilities before reaching safety. Heavy-handed use of broad-spectrum drugs is known to spur drug resistance. And, hopping from one chaotic health care facility to the next provides opportunities for fragile patients to pick up and spread multi-drug resistant infections from bacteria that lurk in health care settings—aka nosocomial infections.
In 2021, Ukrainian researchers published a study characterizing the drug resistance of bacteria plaguing military hospitals in the country, finding rates of resistance much higher than in civilian hospitals in the country and Europe. For instance, among isolates of Acinetobacter baumannii, a common cause of nosocomial infections, 68 percent were resistant to carbapenem antibiotics, a class of antibiotics often used as a last-line defense.
The threat of those lurking superbugs is realized in the case report of the Ukrainian soldier, a man in his mid-50s. He was injured in a vehicle fire and sustained third-degree burns on 60 percent of his body. He was initially treated in a facility near Dnipro, Ukraine, before being moved to Kyiv and then to a US military hospital in Germany.
In Germany, health care providers screened his blood, urine, respiratory, and peri-rectal samples for infections. They turned up six distinct, extensively drug-resistant (XDR) infections: A. baumannii, Enterococcus faecium, Klebsiella pneumoniae, and three distinct types of P. aeruginosa. Each one was resistant to many types of antibiotics. The K. pneumoniae, another common nosocomial infection, was resistant to every type of antibiotic tested. It carried 24 antimicrobial resistance genes. It also toted genetic markers of hypervirulence.
The A. baumannii isolate carried 18 antimicrobial resistance genes, though it appeared still susceptible to at least four antibiotics. The three P. aeruginosa isolates were all distinct strains, but all were resistant to 20 of 23 antibiotics tested. And the E. faecium isolate carried eight antimicrobial resistance genes and was resistant to vancomycin, another last-line antibiotic.
The authors of the case report, led by Patrick Mc Gann, a microbiologist and deputy director of the Multidrug-Resistant Organism Repository and Surveillance Network at Walter Reed Army Institute of Research in Maryland, again stressed the threat of drug-resistant bacteria spreading out of Ukraine: “Healthcare practitioners treating citizens of Ukraine need to be cognizant of the increased risk for [multi-drug resistant] organism transmission and infection imposed by the conflict in Ukraine and implement appropriate infection control measures to mitigate their spread.”