Can antimicrobial stewardship programmes be implemented during an armed conflict? A retrospective interventional...

Armed conflicts exacerbate the burden of antimicrobial resistance (AMR) by disrupting healthcare systems, driving the emergence and spread of multidrug-resistant organisms. Antimicrobial stewardship (AMS) is a key strategy to optimize antimicrobial use and preserve treatment options, yet its feasibility during conflict remains underexplored. This study assessed the feasibility and impact of an AMS programme introduced in a civilian hospital within the trauma evacuation pathway in Ukraine during an active conflict.

Using a retrospective, quasi-experimental before-and-after cohort design, outcomes were assessed across antibiotic consumption, prescribing patterns by WHO AWaRe category, mean antibiotic cost per course and hospital length of stay.

Total antibiotic consumption decreased significantly, driven by reductions in third- and fourth-generation cephalosporins and fluoroquinolones, but this occurred alongside an increase in carbapenem use, indicating redistribution of prescribing rather than uniform reduction across classes. AWaRe analysis showed increased Access prescribing and reduced Reserve use overall. Monthly antibiotic costs decreased by 40.5%, and the median length of stay fell by 20.7%.

This study provides evidence that AMS can be implemented and sustained within a civilian hospital during active conflict, despite the operational challenges of war. Stewardship may optimize antimicrobial selection and costs, although reductions in total use occurred alongside increased reliance on carbapenems in response to local resistance pressures. These findings underscore the need to embed AMS as a core component of humanitarian health responses, while maintaining continuous surveillance to detect and mitigate emerging selective pressure for multidrug-resistant organisms associated with intensified antimicrobial use.