Stopping Superbugs Before They Stop Us: A New Approach to Battlefield Infection
- Dr. Hailie Uren and Surgeon Solomiia Voitsekhovska
- 6 hours ago
- 4 min read
Between us, we see both ends of the same problem. One of us tracks resistant organisms through the surveillance data; the other reconstructs the tissue they have destroyed. The picture from both ends is the same: up to 37 per cent of casualties who reach definitive care in Ukraine are carrying infections resistant to every antibiotic available. Some are resistant to drugs that did not exist as a resistance target three years ago. In 2024, we identified carbapenem-resistant gram-negative bacteria in Ukrainian samples that carry no carbapenemase enzymes — organisms that bypass the mechanisms our surveillance systems are built to detect. They were absent from samples in 2022 and 2023. The resistance is evolving faster than our ability to characterise it.
If up to a third of casualties arriving at definitive care harbour pan-resistant infections, their trajectory begins to parallel chemical, biological, radiological, and nuclear incidents. The same logic of containment, decontamination, and timing applies.
How a Wound Becomes a Superbug
The pathway is predictable. Most injuries in Russia’s war against Ukraine result from explosive ordnance — severe, heavily contaminated wounds compounded by substantial soft tissue and bone damage. Movement of the wounded is routinely delayed The delays to evacuation are a median time of 8 hours, but can extend to days or even weeks. This has to be done by night to allow evacuation to reduce to likelihood of detection. During that time, contamination advances to colonisation. Without timely irrigation, debridement, and appropriate prophylaxis, colonisation advances to infection.
In the NATO Standard AJP- 4.10 Allied Joint Doctrine For Medical Support, the Functions And Capabilities of Military Health Careare described by Roles, with each successive Role building on the minimum capabilities of the previous one.
Approximately 80 per cent of war-wounded casualties transfer to civilian hospitals, admitted to multi-bed wards alongside routine presentations. We have documented nursing ratios of one clinician to twenty or thirty patients — insufficient to wash patients, change dressings, or administer intravenous antibiotics more than twice daily. In those conditions, Multidrug-Resistant Organisms (MDROs) move from war-wounded casualties to the civilian patients beside them with efficient cross-transmission. People who came to hospital for routine care are acquiring untreatable infections from the bed next door.
24–37% | of casualties harbour pan-resistant infections on arrival at Role 4 definitive care |
1:20–30 | nursing ratios in civilian wards receiving war-wounded — too low for effective infection prevention |
70 km | from a major Role 4 hospital in Lviv to the EU border: the geographic scale of the risk |
6–12 hrs | typical pre-evacuation delay during which wound contamination advances unchecked |
This Is Not New — But Ukraine Is Different
MDRO spread in conflict is not unique to Ukraine. In Iraq and Afghanistan, Acinetobacter baumannii spread from field hospitals to referral centres in Germany and then to the United States despite comparatively rapid evacuation and better-resourced infection control. The mechanism — colonised casualties moving through a care chain with insufficient controls at transfer points — is consistent across conflicts.
What distinguishes Ukraine is scale and convergence. Loss of air superiority has extended evacuation windows beyond anything in modern comparable conflict. Casualty volumes have overwhelmed civilian infrastructure. Months of broad-spectrum prescribing under conditions where targeted treatment is operationally impossible have produced resistance mechanisms absent from our samples three years ago. Ukraine-associated MDROs are already documented in clinical settings in Germany, the Netherlands, and Poland. One of the largest Role 4 hospitals in Ukraine is 70 kilometres from the EU border.
The Paradigm Shift: Treat Contamination Like a CBRN Incident
The clinical framing needs to change. When casualties arrive at hospital carrying organisms whose consequences — rapid progression, cross-contamination, high mortality, need for containment — parallel biological warfare exposure, the principles of CBRN doctrine apply. The decisive insight is that timing is everything: decontamination at the earliest point of contact changes the outcome. Waiting until the patient reaches the ward is already too late.
We propose a decontamination cascade across the evacuation chain. At point of injury: antiseptics and wound irrigation as standard equipment; single-dose narrow-spectrum prophylaxis replacing broad-spectrum cover. At the trauma stabilisation point: full-body antiseptic decontamination following life-saving interventions, with high-volume irrigation and debridement. At hospital entry: a dedicated decontamination unit removes contaminated clothing, replaces lines and catheters, and completes external decontamination before the patient enters the ward. The goal is to interrupt the contamination cascade at the earliest point where it can be interrupted — not to manage consequences that have become untreatable.
What This Means for the Medevac Chain
The wounds that reach the operating table in the best condition are those where something disciplined happened upstream. The ThermoTraumaPort device — central to the discussion at the Frontline Club on 26 May — addresses a related dimension of the same problem: the physiological vulnerability created by cold transfer surfaces, repeated handovers, and hypothermia during the medevac window. A compromised physiological state is a more permissive environment for the organisms we track. Upstream decontamination and thermal stabilisation during transfer are not competing interventions. They are components of a system that does not yet fully exist. Building that system is what the conversation on 26 May needs to advance.
Frontline Innovation: Medical Evacuation — 26 May 2026, Frontline Club, London
About the Authors
Hailie Uren leads antimicrobial resistance and infection control research at the SI Center for Public Health of the Ministry of Health of Ukraine, and is a researcher in pharmacy and pharmacology at Griffith University, Gold Coast. Her work spans MDRO surveillance, stewardship in conflict settings, and the spread of war-associated resistant organisms across the European evacuation pathway.
Solomiia Voitsekhovska is a plastic surgeon in Kyiv, who has worked throughout Russia’s full-scale invasion managing complex wound reconstruction in war-injured casualties, including the late-stage infections that follow prolonged and inadequately controlled evacuation.
This briefings is based on the research of Uren H, Berrey BH, Gumeniuk K, et al. “War against superbugs, stopping them before they stop us: a biological warfare approach to safeguard European biosecurity.” Trauma Surgery & Acute Care Open 2026;11:e002169. Open access. doi:10.1136/tsaco-2025-002169
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