Following the publication of the Lancet Commission on Ukraine, authors Guido Granata and colleagues issued a correspondence emphasizing that antimicrobial resistance (AMR) constitutes an existential global threat, with conflict exacerbating risks of hospital-acquired infections and resistant pathogen transmission. They argue that strengthening infection prevention and control (IPC) measures is essential for sustaining health system resilience and patient safety, irrespective of AMR’s explicit presence, particularly in fragile settings like Ukraine where healthcare infrastructure faces sustained strain.
Why Strengthening Infection Control in Conflict Zones Is a Global Health Imperative
This correspondence matters because it reframes AMR not merely as a pharmacological challenge but as a systems failure amplified by war, displacement, and collapsed sanitation. In Ukraine, over 1,000 healthcare facilities have been damaged or destroyed since 2022, disrupting sterilization protocols and increasing reliance on broad-spectrum antibiotics in overwhelmed hospitals. Without robust IPC—such as hand hygiene, sterilization of equipment, and isolation of infectious patients—resistant strains like carbapenem-resistant Klebsiella pneumoniae (CRKP) spread rapidly, threatening not only local populations but also regional health security through cross-border patient movement and medical evacuation. The World Health Organization estimates that in conflict-affected areas, healthcare-associated infections (HAIs) can increase by 40–60%, directly driving inappropriate antibiotic leverage and resistance selection.
In Plain English: The Clinical Takeaway
- War damages hospitals and disrupts hygiene, making infections more likely and harder to treat.
- Simple steps like cleaning hands and equipment can stop deadly germs from spreading, even without new drugs.
- Protecting hospitals in conflict zones protects everyone, because resistant infections don’t respect borders.
The Hidden Epidemic: How War Fuels Silent Spread of Resistant Pathogens
Beyond immediate trauma care, prolonged conflict creates ideal conditions for AMR proliferation. Destroyed water and sanitation systems increase exposure to fecal pathogens, while interrupted supply chains lead to substandard or counterfeit antibiotics—both factors that accelerate resistance development. A 2024 study in The Lancet Infectious Diseases found that in Ukrainian hospitals operating near frontlines, the prevalence of multidrug-resistant organisms (MDROs) in intensive care units rose from 18% pre-conflict to 52% by 2023, with Acinetobacter baumannii showing particularly high resistance to carbapenems, last-line antibiotics used when others fail. This is not merely a Ukrainian issue: medical evacuations to EU countries have imported resistant strains, prompting heightened surveillance in Germany, Poland, and Romania.
Critically, the authors note that IPC interventions yield dual benefits: they reduce HAIs regardless of resistance status and decrease the selective pressure that drives resistance evolution. For example, implementing bundled interventions—such as chlorhexidine bathing, ventilator-associated pneumonia (VAP) bundles, and antimicrobial stewardship—has been shown in conflict-adjacent settings to lower HAIs by up to 30% and reduce carbapenem use by 25%, according to data from the International Committee of the Red Cross (ICRC) surgical facilities in Yemen and Syria.
Global Policy Gaps and the Role of Regional Health Authorities
While the WHO’s Global Action Plan on AMR emphasizes IPC as a cornerstone, implementation in fragile states remains underfunded. The European Centre for Disease Prevention and Control (ECDC) reported in 2025 that only 35% of EU member states have fully integrated conflict-sensitive AMR surveillance into their national action plans, despite receiving over 12,000 medically evacuated patients from Ukraine since 2022. In the United States, the CDC’s Antibiotic Resistance Solutions Initiative allocates grants for global IPC capacity building, but less than 8% of its 2024 funding targeted active conflict zones. Meanwhile, the UK’s National Health Service (NHS) has strengthened screening protocols for patients arriving from Ukraine, requiring rectal swabs for MDRO detection upon admission to certain NHS trusts—a measure credited with preventing several hospital outbreaks in 2023–2024.
These disparities highlight a critical gap: while high-income countries bolster domestic defenses, investment in frontline IPC in war zones remains fragmented. The authors call for binding commitments from G7 nations to allocate at least 0.1% of their defense budgets to healthcare resilience in conflict-affected areas—a proposal echoed by the UN Secretary-General’s 2024 report on protecting civilians in war.
Funding, Bias Transparency, and Expert Perspectives
The Lancet Commission on Ukraine was funded by the Wellcome Trust and the Bill & Melinda Gates Foundation, with no direct industry involvement. Authors declared no competing interests related to antimicrobial products. To provide independent insight, we sought comment from Dr. Margaret Humphries, PhD, lead epidemiologist at the WHO’s Antimicrobial Resistance Division.
“In conflict settings, we’re not just fighting bacteria—we’re fighting broken systems. Investing in infection prevention isn’t secondary to peacebuilding. it’s foundational. Every dollar spent on sterile processing or hand hygiene stations in a war hospital reduces the require for last-resort antibiotics and protects both local populations and the global community.”
Dr. Oleksandr Kovtun, MD, Head of Infection Control at Kyiv Municipal Clinical Hospital No. 4, shared frontline observations:
“Before 2022, we saw maybe one case of carbapenem-resistant infection per month. Now, we screen for it weekly in ICU patients. Without consistent access to autoclaves and alcohol-based hand rub, we’d be overwhelmed. Simple tools save lives when the system is breaking.”
Evidence Snapshot: Impact of IPC Interventions in Resource-Limited Settings
| Intervention | Setting | HAI Reduction | Antibiotic Use Change | Source |
|---|---|---|---|---|
| Hand hygiene + environmental cleaning | ICRC surgical units, Yemen | 32% | ↓ 22% cephalosporins | BMJ Glob Health 2024 |
| VAP bundle implementation | Field hospital, Syria | 28% | ↓ 19% meropenem | Lancet Reg Health Eur 2024 |
| Antimicrobial stewardship + IPC | Referral hospital, Ukraine | 35% | ↓ 27% carbapenems | Clin Infect Dis 2024 |
Contraindications & When to Consult a Doctor
This discussion does not involve a specific drug or therapy, so traditional contraindications do not apply. However, individuals should seek immediate medical attention if they develop signs of systemic infection—such as fever >38.5°C (101.3°F), worsening pain at a wound site, confusion, or rapid heart rate—especially after recent hospitalization, surgery, or exposure to healthcare settings in conflict-affected regions. Patients with compromised immunity (e.g., due to chemotherapy, HIV, or immunosuppressive therapy) are at heightened risk for severe outcomes from MDROs and should inform clinicians of any recent travel or medical care abroad. Early diagnosis through cultures and prompt isolation are critical to prevent transmission.
There are no known risks to following IPC principles; in fact, consistent hand hygiene and environmental cleaning are universally beneficial and carry no adverse effects. Misinformation suggesting that soap and water or alcohol-based rubs “weaken immunity” is categorically false and contradicted by decades of clinical evidence.
The Path Forward: Integrating IPC into Humanitarian and Defense Planning
The authors’ reply serves as a vital reminder that AMR containment cannot be divorced from the realities of war. Sustainable solutions require embedding IPC into humanitarian logistics, military medical planning, and post-conflict reconstruction—treating sterilization equipment, clean water, and trained hygiene officers as essential as bandages and blood products. Initiatives like the Global Antibiotic Research and Development Partnership (GARDP)’s operate on infection prevention kits for field hospitals offer scalable models, but their reach remains limited by funding volatility.
As we mark two years since the escalation of war in Ukraine, the lesson is clear: protecting patients from resistant infections begins not in the pharmacy, but at the sink. Handwashing, sterile instruments, and vigilant surveillance are not luxuries—they are the first line of defense in a world where conflict and microbes evolve in tandem. Until every hospital, even in the most broken places, can guarantee basic hygiene, the threat of AMR will continue to outpace our drugs.
References
- The Lancet Infectious Diseases. 2024;24(5):501-512. Antimicrobial resistance in Ukrainian war hospitals.
- BMJ Glob Health. 2024;9(3):e014567. Impact of WASH interventions on HAIs in Yemen.
- Lancet Reg Health Eur. 2024;42:100910. VAP prevention in Syrian field hospitals.
- Clin Infect Dis. 2024;78(11):1987-1996. Stewardship and IPC in Kyiv referral hospital.
- WHO. 2024. Global Antimicrobial Resistance and Use Surveillance System (GLASS) Report.
