The Evolving Frontline of Antimicrobial Resistance: Adapting Testing and Treatment for Austere and Combat Settings

The conflict in Ukraine highlights the significant challenges posed by antimicrobial resistance (AMR) in resource-limited and combat settings. Alarming rates of multidrug-resistant organisms, including carbapenem-resistant organisms causing up to 60% of healthcare-associated infections, have been reported from Ukrainian hospitals during the conflict. This narrative review examines the current landscape and potential application of diagnostic testing and antimicrobial treatments for high-priority MDROs relevant to these settings, specifically carbapenem-resistant Enterobacterales (CRE), carbapenem-resistant Acinetobacter baumannii complex, and carbapenem-resistant Pseudomonas aeruginosa.

This narrative review synthesized information from relevant scientific literature and expert knowledge concerning AMR diagnostics and therapeutics. The focus was on evaluating the application and limitations of current and novel strategies for managing CRE, carbapenem-resistant A. baumannii complex, and carbapenem-resistant P. aeruginosa in resource-limited and combat environments, using the ongoing conflict in Ukraine as a key contextual example. We did not employ a systematic literature search protocol.

Diagnostic capabilities in resource-limited settings are often constrained, limiting effective AMR surveillance and targeted therapy. Traditional culture and basic antimicrobial susceptibility testing (AST) face challenges; adaptations like direct disk diffusion and deployable molecular tests offer enhanced capability closer to the field. Newer diagnostics like MALDI-TOF and NGS show promise, but face implementation hurdles related to cost, infrastructure, and interpretation. Treatment in resource-limited and combat settings, such as during the conflict in Ukraine, is severely constrained by a complex intersection of logistical and clinical barriers. These obstacles include a lack of regional epidemiology data, as well as significant supply chain issues involving cold chain requirements, drug instability, and the need for sterile compounding. Furthermore, the administration of novel agents against carbapenem-resistant pathogens is often impractical in austere environments due to the necessity for frequent dosing, prolonged infusion times, and reliable intravenous access. The ongoing development of ultra-broad-spectrum oral agents represents a vital advancement that may facilitate rapid treatment initiation far-forward without the burden of cold-chain logistics or complex IV equipment.

AMR presents a critical threat in conflict and resource-limited settings, exacerbated by challenges in diagnostics and treatment logistics. Although novel diagnostic technologies and antimicrobial agents provide potential solutions for managing infections caused by resistant organisms, significant barriers to their effective implementation exist. Addressing these obstacles requires targeted research and adaptation of strategies to ensure optimal deployment of diagnostics and therapeutics in austere environments.