Authors: Nurse Practitioner ID Rena Patierno , Trauma Program Manager Elwood Conaway ,

Abstract

Introduction

 Armed conflicts have been implicated in the development of antimicrobial resistance. Cases of antimicrobial-resistant microorganisms among people with war injuries were first documented during World War II and have been increasingly reported in more recent conflicts (Mende et al., 2022). As the survival of military personnel wounded in previous wars increased due to advancements in personal protective equipment and combat casualty care, there was a corresponding rise in trauma-related infections (Tribble et al, 2011). Combat trauma across the modern battlefields has revealed an alarming increase in multidrug–resistant organisms (MRDO). During these wars, the most common combat trauma–related infections were skin and soft–tissue (41%), pneumonia (13%), bloodstream infections (13%), osteomyelitis (6%), and sepsis (4%) (Tribble et al, 2016). Infection has been a complication of war wounds throughout history. Extremity wounds are the most prevalent injury pattern among combat casualties (Petfield et al, 2022). Wounds from blasts, gunfire, and shrapnel are often heavily contaminated and difficult to sterilize in austere environments. Data from Iraq, Afghanistan, and Ukraine demonstrate a continuum of resistance evolution—from multidrug resistance (MDR) to extensively drug-resistant (XDR) and even pan-resistant pathogens—posing a serious threat to military readiness and global health.

Aim

 As management of combat trauma–related infections became more complicated due to multidrug resistance, extensively drug-resistant, and pan-drug-resistant infections, understanding the microbiology of war wounds became essential to improve treatment and maximize patient outcomes. The ongoing examination of combat-related infections, including the determination of antibiotic resistance in isolated pathogens, is critical to maximizing patient care and preventing the global spread of antibiotic resistance. We conducted a literature review to compare epidemiology, pathogens, and resistance trends across Iraq, Afghanistan, and Ukraine.

Methods

 The research was conducted by reviewing the literature obtained through the MEDLINE & PEBMED databases. The search terms "war" (Afghanistan, Iraq, Ukraine), "armed conflicts," and "antibiotic resistance" were used in the MEDLINE database. Filters were applied to include publications dated January 2008 to August 2025. This would cover the early stages of the wars in Iraq, Afghanistan, and the current conflict in Ukraine. Qualitative information was summarized by means of textual descriptions. While reviewing the included studies, the team adopted the definitions of MDR as bacteria that are non-susceptible to agents in three or more antimicrobial categories, XDR as bacteria that are non-susceptible to agents in all but two or fewer antimicrobial categories, and PDR as bacteria that are non-susceptible to all agents in all antimicrobial categories.

Discussion

 Research confirms that, because of war and for the future of large-scale operations, a large pool of multidrug-resistant infections can have a global impact on healthcare. The latest Military Health System recommendations for treating monthly drug-resistant infections in the combat zone emphasize infection prevention, antimicrobial stewardship, rapid diagnostics, and evidence-based antibiotic selection, with most cases managed without evacuation.

Combat zone infections are frequently caused by multidrug-resistant (MDR) organisms, especially Gram-negative bacteria such as Pseudomonas aeruginosa and Acinetobacter baumannii, as well as extended-spectrum β-lactamase (ESBL)-producing Enterobacter ales (Anderson, 2024). Approximately one-third of combat casualties develop infections during initial hospitalization, with skin, soft tissue, and bone infections being most common (Weintraub, 2025). Risk factors for infection include severe injury (high Injury Severity Score), traumatic amputations, multiple surgeries, and ICU admission.

Conclusion

 In summary, the latest data reveal a serious and worsening issue with multidrug-resistant (MDR), extensively drug-resistant (XDR), and MDR infections among combat casualties. These infections exhibit high resistance to nearly all available antibiotics, including last-resort options, posing a significant risk of global spread. Research indicates an exceptionally high level of resistance to carbapenems, fluoroquinolones, and aminoglycosides, as well as a considerable prevalence of MDR in gram-negative bacteria compared to gram-positive microbes. To limit nosocomial transmission and prevent outbreaks in both military and civilian settings, infection prevention and control (IPC) measures—such as hand hygiene, surveillance, and pre-deployment training—are crucial.

Keywords: Military Medicine, Trauma, Multi Drug Resistance