---
title: "Multidrug-Resistant Organisms in Combat Injuries: Evidence from Iraq, Afghanistan, and Ukraine"
id: "pubmed-42763423"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42763423"
content_type: "clinical_feed_article"
specialty: "Infectious Disease"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42763423/"
doi: "10.1093/milmed/usag428"
published_at: "2026-09-20T00:00:00.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Multidrug-Resistant Organisms in Combat Injuries: Evidence from Iraq, Afghanistan, and Ukraine
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42763423
- **Specialty:** [Infectious Disease](https://medichelpline.com/clinical-feed/infectious-disease.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42763423/)
- **DOI:** [10.1093/milmed/usag428](https://doi.org/10.1093%2Fmilmed%2Fusag428)
- **Published At:** 2026-09-20T00:00:00.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- Armed conflict drives **antimicrobial resistance**, and multidrug-resistant organisms (MDROs) in combat-related infections are a major challenge for modern military trauma care. - This narrative review synthesized English-language literature from January 2008 through April 2026 on MDROs in combat injuries from Iraq, Afghanistan, and Ukraine. - Standard consensus definitions for **MDR**, **XDR**, and **PDR** were used. - Combat-related infections are mainly polymicrobial and dominated by **Gram-negative bacilli**, notably **Acinetobacter baumannii**, **Pseudomonas aeruginosa**, and carbapenem-resistant Enterobacterales. - The Trauma Infectious Disease Outcomes Study (TIDOS) found MDR Gram-negative infection in about **27%** of infected casualties from Iraq and Afghanistan. - Surveillance from Ukraine shows escalation in resistance: meropenem resistance up to **72%** in A. baumannii and **83%–91%** in Klebsiella pneumoniae, with co-production of NDM-1, OXA-48, and KPC-2 carbapenemases. - Reports indicate frequent resistance to last-line agents including **cefiderocol** and **ceftazidime-avibactam**, and convergence of resistance and hypervirulence in international high-risk clones. - Frontline wound cultures suggest MDRO acquisition is mainly **nosocomial**, occurring along the evacuation chain rather than at point of injury. - Repatriation of foreign combatants colonized by XDR organisms creates an unprecedented risk of international dissemination. - Mitigation strategies recommended include standardized antimicrobial protocols across Role 1 and Role 2 care, centralized oversight by the **Defense Health Agency**, deployable rapid diagnostics, strengthened stewardship and infection prevention, and resilient logistics (including drone-enabled resupply) to preserve antimicrobial effectiveness and operational readiness.
## Clinical Analysis & Structured Key Points
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Online ahead of print. # Multidrug-Resistant Organisms in Combat-Related Injuries: Insights from Iraq, Afghanistan, Ukraine, and Implications for Large-Scale Combat Operations [Rena Patierno](https://pubmed.ncbi.nlm.nih.gov/?term=Patierno+R&cauthor_id=42763423)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42763423/#full-view-affiliation-1 "Medical Associates of Hudson Valley, Kingston, NY, United States."), [Elwood Conaway](https://pubmed.ncbi.nlm.nih.gov/?term=Conaway+E&cauthor_id=42763423)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42763423/#full-view-affiliation-2 "Johns Hopkins Bayview Medical Center, Baltimore, MD, United States."), [Marcelo A F Riberio Jr](https://pubmed.ncbi.nlm.nih.gov/?term=Riberio+MAF+Jr&cauthor_id=42763423)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42763423/#full-view-affiliation-3 "R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States.") Affiliations Expand ### Affiliations * 1 Medical Associates of Hudson Valley, Kingston, NY, United States. * 2 Johns Hopkins Bayview Medical Center, Baltimore, MD, United States. * 3 R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States. * PMID: **42763423** * DOI: [ 10.1093/milmed/usag428 ](https://doi.org/10.1093/milmed/usag428) Item in Clipboard # Multidrug-Resistant Organisms in Combat-Related Injuries: Insights from Iraq, Afghanistan, Ukraine, and Implications for Large-Scale Combat Operations Rena Patierno et al. Mil Med. 2026. Show details Display options Display options Format Abstract PubMed PMID Mil Med Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Mil+Med%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Mil+Med%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42763423/) . 2026 Sep 20:usag428. doi: 10.1093/milmed/usag428. Online ahead of print. ### Authors [Rena Patierno](https://pubmed.ncbi.nlm.nih.gov/?term=Patierno+R&cauthor_id=42763423)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42763423/#short-view-affiliation-1 "Medical Associates of Hudson Valley, Kingston, NY, United States."), [Elwood Conaway](https://pubmed.ncbi.nlm.nih.gov/?term=Conaway+E&cauthor_id=42763423)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42763423/#short-view-affiliation-2 "Johns Hopkins Bayview Medical Center, Baltimore, MD, United States."), [Marcelo A F Riberio Jr](https://pubmed.ncbi.nlm.nih.gov/?term=Riberio+MAF+Jr&cauthor_id=42763423)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42763423/#short-view-affiliation-3 "R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States.") ### Affiliations * 1 Medical Associates of Hudson Valley, Kingston, NY, United States. * 2 Johns Hopkins Bayview Medical Center, Baltimore, MD, United States. * 3 R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States. * PMID: **42763423** * DOI: [ 10.1093/milmed/usag428 ](https://doi.org/10.1093/milmed/usag428) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID ## Abstract **Introduction:** Armed conflict is a powerful driver of antimicrobial resistance, and combat-related infections caused by multidrug-resistant organisms (MDROs) have emerged as a defining challenge of modern military trauma care. Reports from Iraq, Afghanistan, and the ongoing conflict in Ukraine document a clear progression from multidrug-resistant to extensively drug-resistant (XDR) and pan-drug-resistant (PDR) pathogens. This review synthesizes current evidence on combat-related MDRO infections during large-scale combat operations (LSCO) and prolonged field care (PFC). **Methods:** A narrative literature review was conducted using MEDLINE/PubMed for English-language publications from January 2008 through April 2026, combining the terms war, armed conflict, combat injury, Iraq, Afghanistan, Ukraine, antimicrobial resistance, and multidrug-resistant organisms. Eligible sources included peer-reviewed original research, systematic and narrative reviews, and military clinical guidelines. Standard consensus definitions were used for MDR, XDR, and PDR. **Results:** Combat-related infections are predominantly polymicrobial and dominated by Gram-negative bacilli, particularly Acinetobacter baumannii, Pseudomonas aeruginosa, and carbapenem-resistant Enterobacterales. The Trauma Infectious Disease Outcomes Study (TIDOS) demonstrated MDR Gram-negative infection in approximately 27% of infected casualties from Iraq and Afghanistan. Surveillance from Ukraine reveals a qualitative escalation: meropenem resistance reaches 72% in A. baumannii and 83%-91% in K. pneumoniae, with co-production of NDM-1, OXA-48, and KPC-2 carbapenemases, frequent resistance to last-line agents (cefiderocol, ceftazidime-avibactam), and convergence of resistance and hypervirulence in international high-risk clones. Frontline wound cultures suggest that MDR acquisition is predominantly nosocomial, occurring along the evacuation chain rather than at the point of injury. Repatriation of foreign combatants colonized by XDR organisms now represents an unprecedented international dissemination risk. **Conclusions:** The MDRO burden in combat casualties is escalating in scale and severity, with direct implications for LSCO and PFC. Mitigation requires standardized antimicrobial protocols across Role 1 and Role 2 levels of care, centralized oversight by the Defense Health Agency, deployable rapid diagnostics, robust stewardship and infection-prevention programs, and resilient logistics-including drone-enabled medical resupply-to maintain antimicrobial effectiveness and operational readiness. © The Association of Military Surgeons of the United States 2026. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. 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