The Department of Defense wants U.S. researchers to study antibiotic-resistant wounds in Ukraine to help improve the country’s medical care and prepare U.S. troops and medical personnel to encounter similar challenges in a future war.
In hospitals across Ukraine, doctors are increasingly having trouble treating the wounds of civilian and military patients because of rising antibiotic resistance. The strain on the healthcare system is getting worse, Ukrainians are growing resistant to available medicines and the nation’s morbidity rates are increasing, said Dr. Roman Fishchuk, an ear, nose and throat doctor who will be collecting data from frontline hospitals in Ukraine to support the Pentagon-funded study.
“You have a bacterial infection, you’d treat the bacterial infection with an antibiotic or if you have a viral infection, you treat the patient with antivirals, but if the patient is resistant to antibiotics, then you cannot treat the cause of the disease,” Fishchuk told Task & Purpose. “You can’t help the patient in many ways. You’re very limited with the options you have for that patient.”
In 2023, an international public health coalition said that antimicrobial resistance in Ukraine is “an urgent crisis that must be addressed, even during an ongoing war” and urged for more work on the prevention, detection, and response on the issue “to save lives within Ukraine and limit international spread.”
The coalition’s work was supported by U.S.-provided Ukraine emergency funding passed by Congress and looked at antimicrobial resistance in eastern regions of the country. But now, antibiotic resistance is spreading across the country and even being found in patients evacuated to European hospitals.
“This is something we’ve been receiving from hospitals outside of Ukraine where Ukrainian patients are evacuated to,” Fishchuk said. “Sometimes foreign hospitals do not have anything to treat them with because all of the antibiotics they have, people are resistant to, even children.”
As the issue gets worse, the U.S. military is funding a study to help improve Ukrainian military and civilian medical care, and to assist with the Pentagon’s own planning of future large-scale combat operations.
The project, funded through the DoD’s Combat Casualty Research Program, is led by University of Colorado Anschutz Medical Campus researchers who will work with Ukrainian clinicians to study clinical and logistical challenges with prolonged casualty care and modern large-scale combat operations — a type of warfare the Pentagon anticipates the U.S. may face in the future.
Dr. Adit Ginde, the principal investigator of the project, sees the problem with treating military and civilian casualties in Ukraine as two-fold: medical care is limited on the ground and it has to contend with the growing trend of antibiotic-resistant wounds.
“There’s limited access to evacuation, limited access to care, and so these wounds kind of stay dirty and uncleaned and have a high chance of infection,” Ginde said. “This is one of the huge challenges of caring for those injured in the war and then layering on top of that, there is a large prevalence of antibiotic or antimicrobial resistant bacteria.”
Antibiotic resistance is not war-specific but its impacts on local healthcare systems, improvised field hospitals and an overuse of broad-spectrum antibiotics could exacerbate the problem, according to studies that looked at antibiotic-resistant wound care in Iraq and Afghanistan.
The “rampant use” of antibiotics in agriculture and to treat humans over the past decades have worsened the problem, Ginde said.
“The main reason for antibiotic resistance is actually agriculture because antibiotics are used during the growth of different animals, and that’s why this is one of the major contributors to antibiotic resistance among people,” Fishchuk said.
Bacterial antimicrobial resistance is a leading global health threat and causes more deaths than HIV or malaria worldwide, according to research cited by the Centers for Disease Control. In countries where there are fewer hygiene protocols, such as proper hand washing or wearing medical-grade gowns and masks, the bacteria can spread from patient to patient within a facility and then to different regions or countries if a patient travels, Ginde said.
In Ukraine and in other areas of the world, the most common antibiotic-resistant bacteria are called gram-negative bacteria or “ESKAPE pathogens” which is an acronym for the scientific names of six harmful bacterial pathogens.
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“The bacteria that are around are kind of these superbugs that are resistant to typical antibiotic treatment so that makes it difficult to treat, leads to high rates of complications like amputation or sepsis, which is when infection goes uncontrolled and the death [is] caused by these wound infections,” Ginde said.
Until recently, antibiotics were considered over-the-counter drugs in Ukraine, but in an effort to tamp down rising resistance, Fishchuk said antibiotics are now limited to prescription only.
No more golden hour
Part of the U.S. military’s planning for a large-scale war involves setting realistic expectations for when troops can get medical care.
Limited medical evacuations is something that the Pentagon has focused on in its planning for potential combat scenarios in the Pacific where the U.S. military might not have air superiority and distances between hospitals may be greater than what they were during wars fought in the Middle East.
“The paradigms of this large-scale combat operation that the U.S. military is operating under, it may take 24 to 72 hours for evacuation to occur,” Ginde said.
Combat casualty care previously operated under the premise of a “golden hour” which is seen as a critical 60-minute period that offers injured troops the best chance for successful medical intervention and survival despite a serious wound. In Ukraine, that hour doesn’t exist.
“The major concern is the time it takes to evacuate the person from the east to the west of Ukraine, and if there are airstrikes, which are happening on a regular basis, [then] this delays evacuation of the wounded soldiers and civilians,” Fishchuk said. “Since we do not have air superiority, we do not use any aircraft, so we can’t use helicopters or planes for that.”
To go from east to west by train, Fishchuk said it can take anywhere from 12 to more than 24 hours but added that air transport can increase the speed exponentially. While the Ukrainian military has “stabilization points” close to the front lines, those areas are being hit by Russian strikes on a regular basis, “so they try to transport the patients as soon as possible.” But because of heavy Russian shelling, it’s “pretty much impossible to do that,” he said.
With Ukraine as an example and the Pentagon’s planning for a potential future conflict, the U.S. is looking at prolonged casualty care in the field. But right now the medical combat community doesn’t have the “understanding of the health outcomes and the interventions to help those combat injured in this sort of prolonged care paradigm,” according to Ginde.
Researchers hope their study can help put answers to some of the current gaps.
What the data tells us about trauma care in a large-scale war
One of the other main goals of the project is to contextualize and figure out the scope of the problem which is difficult since Ukraine doesn’t have electronic health records. The country was undergoing an electronic transformation or overhaul over the last few years but those efforts have been stymied by the war, Fishchuk said. A lot of medical documents at Ukrainian hospitals are hand-written which is not ideal for large-scale analysis, researchers said.
“We don’t know the exact rate of the frequency or prevalence of these infections, nor exactly how they lead to the outcomes that we’re trying to avoid: amputation, sepsis and death,” Ginde said. “We just know that it’s very common, and that Ukrainians have raised this as one of their most important medical challenges currently in the current war. The U.S. military also feels like it is one of their most important challenges for planning for future wars.”
Researchers are hoping to launch a platform to study the issue and improve patient care and outcomes.
To build the platform, researchers on the ground like Fishchuk plan to collect basic demographic information and data around injury and wound characteristics like when it occurred, the type of trauma and the mechanism of injury. They’ll also take pictures of the wound and take swabs for an analysis of the wound’s culture to understand the epidemiology and microbiology of wound infections, Ginde said.
As defense contractors, U.S. university researchers aren’t allowed on the ground in Ukraine so they will coordinate the work remotely and meet with Ukrainian clinicians in Poland. Fishchuk will lead in-country efforts over the next two years to collect data at three front-line hospitals in the east and two referral centers in western Ukraine for the study.
By recording and analyzing the wound infections “in a more systematic and scientifically rigorous way,” researchers can recommend where to put more resources to develop solutions and prevention methods. Ginde described current antibiotic-resistant wound treatments as “not adequate.”
There is currently limited access to supplies and knowledge on the most effective treatments for antibiotic-resistant infections. Some current medicines come in the form of topical ointments.
“Our hope is that in 2025 we’ll already have actionable information and data both to understand the microbiology and epidemiology of this condition,” Ginde said, “but also understand how that relates to outcomes and be pushing forward with clinical trials and solutions in 2025.”
Update: 9/16/2024; The headline for this article was updated after publication to more clearly note that the Pentagon is funding research into antibiotic-resistant wounds in Ukraine.
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