Superbugs advance between the trenches of the Ukrainian war

A global enemy, invisible to the naked eye, is quietly gaining ground on the battlefields of Ukraine.

A team of doctors from Germany has warned that bacteria are finding a great opportunity in war to develop new resistance to antibiotics and spread between the wounded and the spaces in which they are cared for.

"These wounded often receive non-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," the specialist in internal medicine María Virginia Dos Santos, from the Charité-University Hospital of Berlin.

This institution is one of the European health centers that has cared for hundreds of wounded in the war in Ukraine since the start of hostilities.

The doctors have thoroughly analyzed the multi-resistant infections found in the bones and soft tissues of 13 civilians and 1 soldier—6 of them wounded by gunshots and 8 by grenade and bomb explosions—transferred to Germany to receive specialized treatment.

The results have made them activate all the alerts.

"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 multi-resistant pathogens, make these injuries extremely complex to treat", Dos Santos defended this Tuesday at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), which closes in Copenhagen (Denmark) after four days of activities.

Since the start of the war in 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 Center for Musculoskeletal Surgery at the Charité-University Hospital Berlin.

Of the 14 patients analyzed, 10 were men and 4 women, among whom there were 3 minors (the youngest was 14 years old).

The oldest casualty was 64. Most infections were bone, followed by implant-associated infections, soft tissue infections, and septic arthritis.

The most common processes occurred in the lower extremities, but almost half of the patients had more than one affected anatomical area and two had multiple infected areas.

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Of all the infections, 13 were due to multidrug-resistant gram-negative organisms (MRGN) —a type of bacteria—, mostly

,

, as well as other pathogens such as staphylococci, enterococci, and fungi.

Of the 25 gram-negative bacterial isolates, almost three-quarters (72%) were resistant to carbapenems and the newer cephalosporins—ceftazidime-avibactam, ceftozolane-tazobactam—which are the antibiotics of last resort used when the infection is not present. refers to those used in the first and second place.

These pathogens are often called "superbugs" for this reason.

Thirty-nine percent of the isolates were also resistant to another antibiotic such as cefiderocol, 20% to colistin, and 96% to ciprofloxacin, one of the most widely used oral antibiotics.

"We have found a completely new spectrum of pathogens for what is expected in Germany," Dos Santos explained.

“In these terrible war wounds, we are seeing a high incidence of multi-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 to be able to cover these multi-drug resistant organisms,” he added.

Of the 14 patients studied, 10 have been discharged although they continue with complex rehabilitation processes to recover the mobility of the extremities affected by war wounds and infections, as well as recover from the emotional impact suffered.

The remaining four are still on treatment, two of whom have developed new acute infections.

The warning launched by the German physicians coincides with the conclusions of studies carried out in other armed conflicts, such as the one in Iraq, in which it had already been observed that the special conditions of wars —with a high number of wounded and precarious means to care for them, which favors the indiscriminate use of antibiotics that are not always the most indicated— have become a source of resistance to antimicrobials whose negative impact on global health goes far beyond the battlefields.

With the help of wars, but also due to the misuse of antibiotics, antivirals and antifungals in peacetime, resistance has become a threat that already causes more deaths than AIDS and malaria.

Just because of the so-called superbugs, resistant to almost all available antibiotics, some estimates suggest that more than 12 million people will die each year in three decades.

A study published by the European Center for Disease Control and Prevention (ECDC) warned five years ago that more than 33,000 people died annually for this reason in Europe alone.

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