{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,6]],"date-time":"2026-11-06T09:28:08Z","timestamp":1793957288572,"version":"4.8.0"},"reference-count":36,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,4,15]],"date-time":"2026-04-15T00:00:00Z","timestamp":1776211200000},"content-version":"unspecified","delay-in-days":14,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Trauma Surg Acute Care Open"],"accepted":{"date-parts":[[2026,2,23]]},"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:p>Russia\u2019s full-scale invasion of Ukraine has transformed both the modern battlefield and the microbial environment surrounding the war-wounded. Explosive injuries, prolonged evacuation, and limited opportunities for early decontamination have contributed to an unprecedented rise in multidrug-resistant organism (MDRO) infections. This paper describes how routine infection prevention and control (IPC) and antimicrobial stewardship (AMS) systems have become inadequate under conflict conditions and how contamination evolves into colonization and then systemic infection as casualties move through the evacuation pathway.<\/jats:p>\n                  <jats:p>Building on the national IPC and AMS strengthening, we outline a complementary crisis intervention: the application of chemical, biological, radiological, and nuclear-inspired decontamination principles to routine trauma care. These measures incorporate structured early irrigation and debridement, antiseptic cleansing, removal of contaminated materials, and the use of dedicated decontamination spaces at hospital entry. They are designed to reinforce existing programs by reducing microbial burden at the earliest point of contact. Implementing this approach aims to disrupt MDRO acquisition and transmission, protect fragile healthcare infrastructure, and mitigate escalating biosecurity risks. Ukraine\u2019s conflict experience has informed the development of this proposed concept, with formal implementation and impact evaluation planned as the next phase of work.<\/jats:p>\n                  <jats:p>LEVEL OF EVIDENCE: Level V (Current Opinion)<\/jats:p>","DOI":"10.1136\/tsaco-2025-002169","type":"journal-article","created":{"date-parts":[[2026,4,15]],"date-time":"2026-04-15T16:55:15Z","timestamp":1776272115000},"page":"e002169","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["War against superbugs, stopping them before they stop us: a biological warfare approach to safeguard European biosecurity"],"prefix":"10.1136","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3787-9496","authenticated-orcid":false,"given":"Hailie","family":"Uren","sequence":"first","affiliation":[{"name":"Antimicrobial Resistance and Infection Control, SI Center for Public Health of the Ministry of Health of Ukraine, Kyiv, Ukraine"},{"name":"Pharmacy and Pharmacology, Griffith University - Gold Coast Campus, Southport, Queensland, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"B. Hudson","family":"Berrey","sequence":"additional","affiliation":[{"name":"University of Florida, Gainesville, Florida, USA"},{"name":"Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kostiantyn","family":"Gumeniuk","sequence":"additional","affiliation":[{"name":"Central Research Scientific Institute of the Armed Forces of Ukraine, Kyiv, Kyiv City, Ukraine"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Volodymyr","family":"Kovalchuk","sequence":"additional","affiliation":[{"name":"Orthopaedics and Traumatology, Shupyk National Healthcare University of Ukraine, Kyiv, Kyiv City, Ukraine"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Olena","family":"Moshynets","sequence":"additional","affiliation":[{"name":"Institute of Molecular Biology and Genetics of the National Academy of Sciences of Ukraine, Kyiv, Kyiv City, Ukraine"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0451-1137","authenticated-orcid":false,"given":"Jennifer M.","family":"Gurney","sequence":"additional","affiliation":[{"name":"Defense Committees on Trauma, Joint Trauma System, JBSA Fort Sam Houston, Texas, USA"},{"name":"Department of Surgery, San Antonio Military Health System, San Antonio, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Douglas","family":"Davis","sequence":"additional","affiliation":[{"name":"Medical College of Wisconsin Department of Radiology, Milwaukee, Wisconsin, USA"},{"name":"Radiology, Froedtert Hospital, Milwaukee, Wisconsin, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7360-8111","authenticated-orcid":false,"given":"Uliana","family":"Pidvalna","sequence":"additional","affiliation":[{"name":"Normal Anatomy, Danylo Halytsky Lviv National Medical University, Lviv, Lviv Oblast, Ukraine"},{"name":"Ukrainian-Polish Heart Center Lviv, Lviv, Ukraine"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4194-517X","authenticated-orcid":false,"given":"Dmytro","family":"Beshley","sequence":"additional","affiliation":[{"name":"Western Military Medical Clinical Center, Lviv Regional Military Administration, Lviv, Lviv Oblast, Ukraine"},{"name":"Cardiovascular Surgery, Ukrainian-Polish Heart Center Lviv, Lviv, Lviv, Ukraine"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yvette","family":"Godwin","sequence":"additional","affiliation":[{"name":"Plastic Reconstructive Surgery, Ross Hall Hospital, Glasgow, Scotland, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shehan","family":"Hettiaratchy","sequence":"additional","affiliation":[{"name":"Department of Surgery and Cancer, Imperial College London, London, England, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roseanne A","family":"Ressner","sequence":"additional","affiliation":[{"name":"Infectious Disease Service, Walter Reed National Military Medical Center, Bethesda, Maryland, USA"},{"name":"Center for Infectious Disease Research, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mykola L","family":"Ankin","sequence":"additional","affiliation":[{"name":"Orthopaedics and Traumatology, Shupyk National Healthcare University of Ukraine, Kyiv, Kyiv City, Ukraine"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Solomiia","family":"Voitsekhovska","sequence":"additional","affiliation":[{"name":"Plastic Surgery, Oxford Medical Group, Kyiv, Kyiv, Ukraine"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frank","family":"Butler","sequence":"additional","affiliation":[{"name":"Joint Trauma System, Committee on Tactical Combat Casualty Care, Fort Sam Houston, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8312-9157","authenticated-orcid":false,"given":"John B","family":"Holcomb","sequence":"additional","affiliation":[{"name":"Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA"},{"name":"Surgery, University of Alabama at Birmingham Health System, Birmingham, Alabama, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,4,15]]},"reference":[{"key":"2026041509550899000_11.2.e002169.1","unstructured":"Johns Hopkins University Applied Physics Laboratory; Georgetown Center for Strategic and International Studies . Wizard Warfare: Ukrainian technological developments overview. Available: https:\/\/www.jhuapl.edu\/sites\/default\/files\/2025-01\/WizardWarfare_final.pdf [Accessed 12 Jul 2025]."},{"key":"2026041509550899000_11.2.e002169.2","unstructured":"Waterhouse J . In Ukraine\u2019s river war, drones mean nowhere is safe. BBC. 2024. Available: https:\/\/www.bbc.com\/news\/world-europe-67991772 [Accessed 12 Jul 2025]."},{"key":"2026041509550899000_11.2.e002169.3","doi-asserted-by":"crossref","first-page":"1001","DOI":"10.1080\/01402390.2024.2385843","article-title":"A one-way attack drone revolution? Affordable mass precision in modern conflict","volume":"47","author":"Plichta","year":"2024","journal-title":"Journal of Strategic Studies"},{"key":"2026041509550899000_11.2.e002169.4","doi-asserted-by":"crossref","first-page":"576","DOI":"10.1080\/13523260.2023.2262792","article-title":"Drones have boots: Learning from Russia\u2019s war in Ukraine","volume":"44","author":"Kunertova","year":"2023","journal-title":"Contemporary Security Policy"},{"key":"2026041509550899000_11.2.e002169.5","doi-asserted-by":"publisher","DOI":"10.1136\/military-2024-002835"},{"key":"2026041509550899000_11.2.e002169.6","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1016\/j.jhin.2024.06.011","article-title":"Temporal evolution of bacterial species and their antimicrobial resistance characteristics in wound infections of war-related injuries in Ukraine from 2014 to 2023","volume":"152","author":"Kovalchuk","year":"2024","journal-title":"J Hosp Infect"},{"key":"2026041509550899000_11.2.e002169.7","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1016\/j.eimc.2024.04.004","article-title":"Characterization of wound infections among patients injured during the Ruso-Ukrainian war in a Role 4 hospital","volume":"42","author":"Rodero Rold\u00e1n","year":"2024","journal-title":"Enferm Infecc Microbiol Clin (Engl Ed)"},{"key":"2026041509550899000_11.2.e002169.8","doi-asserted-by":"publisher","DOI":"10.1136\/military-2023-002527"},{"key":"2026041509550899000_11.2.e002169.9","doi-asserted-by":"publisher","DOI":"10.1136\/military-2024-002863"},{"key":"2026041509550899000_11.2.e002169.10","doi-asserted-by":"crossref","first-page":"51","DOI":"10.7181\/acfs.2024.0074","article-title":"War-related maxillofacial injuries in Ukraine: a retrospective multicenter study","volume":"26","author":"Prysiazhniuk","year":"2025","journal-title":"Arch Craniofac Surg"},{"key":"2026041509550899000_11.2.e002169.11","unstructured":"Rossi A . Blacked-out ambulances and bomb-cratered roads: On the night shift with Ukraine\u2019s military medics. Sky News. 2024. Available: https:\/\/news.sky.com\/story\/blacked-out-ambulances-and-bomb-cratered-roads-on-the-night-shift-with-ukraines-military-medics-13221620 [Accessed 12 Jul 2025]."},{"key":"2026041509550899000_11.2.e002169.12","unstructured":"North Atlantic Treaty Organization Standardization Office (NSO) . NATO standard AJP-4.10 allied joint doctrine for medical support edition C version 1 september 2019. Available: https:\/\/www.coemed.org\/files\/stanags\/01_AJP\/AJP-4.10_EDC_V1_E_2228.pdf [Accessed 19 Jul 2025]."},{"key":"2026041509550899000_11.2.e002169.13","doi-asserted-by":"crossref","first-page":"A1","DOI":"10.1016\/j.bjps.2023.02.035","article-title":"Editorial - A year of war in Ukraine: hope for reconstructive surgery","volume":"78","author":"Hettiaratchy","year":"2023","journal-title":"J Plast Reconstr Aesthet Surg"},{"key":"2026041509550899000_11.2.e002169.14","doi-asserted-by":"crossref","first-page":"S45","DOI":"10.1097\/TA.0000000000004729","article-title":"Conflict zone medical evacuations catalyzing antimicrobial resistance spread and threatening regional health: A retrospective comparative observational study","volume":"99","author":"Uren","year":"2025","journal-title":"J Trauma Acute Care Surg"},{"key":"2026041509550899000_11.2.e002169.15","doi-asserted-by":"crossref","first-page":"e200","DOI":"10.1016\/S1473-3099(25)00116-1","article-title":"Cumulative antibiogram results of over 6800 diagnostic isolates from the First Lviv Territorial Medical Union, Ukraine","volume":"25","author":"Uren","year":"2025","journal-title":"Lancet Infect Dis"},{"key":"2026041509550899000_11.2.e002169.16","doi-asserted-by":"crossref","unstructured":"Kryzhevskyi V , Strokous V , Lifshyts Y , Rybianets Y , Oberniak A , Krikunov A , Iungin O , Potochilova V , Rudnieva K , Petakh P , et al . Case report: Azithromycin-meropenem combination therapy as a low-cost approach to combat PDR gram-negative infections of war wounds in Ukraine. Front Med 2023;10. doi:10.3389\/fmed.2023.1264492","DOI":"10.3389\/fmed.2023.1264492"},{"key":"2026041509550899000_11.2.e002169.17","doi-asserted-by":"crossref","first-page":"101046","DOI":"10.1016\/j.lanmic.2024.101046","article-title":"Severe conflict-associated wound infections complicated by the discovery of carbapenemase-coproducing Pseudomonas aeruginosa in Ukraine","volume":"6","author":"Pallett","year":"2025","journal-title":"Lancet Microbe"},{"key":"2026041509550899000_11.2.e002169.18","doi-asserted-by":"crossref","DOI":"10.1016\/j.lanepe.2025.101274","article-title":"Evolving antimicrobial resistance of extensively drug-resistant Gram-negative severe infections associated with conflict wounds in Ukraine: an observational study","volume":"52","author":"Pallett","year":"2025","journal-title":"Lancet Reg Heal Eur"},{"key":"2026041509550899000_11.2.e002169.19","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1007\/s40121-024-01097-9","article-title":"Carbapenemase-Producing Enterobacterales from Patients Arriving from Ukraine in Poland, March 2022\u2013February 2023","volume":"14","author":"Biedrzycka","year":"2025","journal-title":"Infect Dis Ther"},{"key":"2026041509550899000_11.2.e002169.20","doi-asserted-by":"publisher","DOI":"10.1097\/TA.0b013e318163c421"},{"key":"2026041509550899000_11.2.e002169.21","first-page":"S290","article-title":"Infection prevention and control in deployed military medical treatment facilities","volume":"71","author":"Hospenthal","year":"2011","journal-title":"J Trauma"},{"key":"2026041509550899000_11.2.e002169.22","doi-asserted-by":"publisher","DOI":"10.1086\/518170"},{"key":"2026041509550899000_11.2.e002169.23","doi-asserted-by":"publisher","DOI":"10.1097\/TA.0b013e31819d894c"},{"key":"2026041509550899000_11.2.e002169.24","unstructured":"Ministry of Health of Ukraine . On approval of the procedure for the prevention of infectious diseases associated with the provision of medical care in healthcare institutions providing inpatient care. Kyiv (UA) Ministry of Health of Ukraine; 2021. 11."},{"key":"2026041509550899000_11.2.e002169.25","unstructured":"State Strategy for Combating Antimicrobial Resistance for the Period until 2030, No. 1265-r, Cabinet of Ministers of Ukraine. 2024. Available: https:\/\/zakon.rada.gov.ua\/laws\/show\/1265-2024-%D1%80 [Accessed 1 Oct 2025]."},{"key":"2026041509550899000_11.2.e002169.26","doi-asserted-by":"crossref","DOI":"10.1016\/j.jinf.2024.106312","article-title":"Pandrug-resistant Klebsiella pneumoniae isolated from Ukrainian war victims are hypervirulent","volume":"89","author":"Ljungquist","year":"2024","journal-title":"J Infect"},{"key":"2026041509550899000_11.2.e002169.27","doi-asserted-by":"crossref","first-page":"85","DOI":"10.55460\/SW7X-X8ZP","article-title":"Antibiotics in Tactical Combat Casualty Care 2025: TCCC Change 25-1","volume":"25","author":"Wisniewski","year":"2025","journal-title":"J Spec Oper Med"},{"key":"2026041509550899000_11.2.e002169.28","unstructured":"Ministry of Health of Ukraine . Standard of medical care: prevention of infectious complications of combat wounds with antibacterial agents at the prehospital stage. 2023. Available: https:\/\/moz.gov.ua\/uploads\/9\/46891- dn_1004_01062023_dod.pdf [Accessed 5 Jan 2025]."},{"key":"2026041509550899000_11.2.e002169.29","doi-asserted-by":"publisher","DOI":"10.1080\/10903120903144841"},{"key":"2026041509550899000_11.2.e002169.30","unstructured":"North Atlantic Treaty Organization Standardization Office (NSO) . Standards related document srd 4 to ajmedp-4 field hygiene and sanitation edition a version. 2020. Available: https:\/\/www.coemed.org\/files\/stanags\/01_AJP\/AJP-4.10_EDC_V1_E_2228.pdf [Accessed 19 Jul 2025]."},{"key":"2026041509550899000_11.2.e002169.31","doi-asserted-by":"publisher","DOI":"10.1086\/657136"},{"key":"2026041509550899000_11.2.e002169.32","doi-asserted-by":"publisher","DOI":"10.29074\/ascls.21.2.102"},{"key":"2026041509550899000_11.2.e002169.33","doi-asserted-by":"crossref","first-page":"1517","DOI":"10.1007\/s15010-025-02523-x","article-title":"Healthcare professionals challenged by 14 distinct carbapenemase-producing micro-organisms in a war-injured Ukrainian patient","volume":"53","author":"Plantinga","year":"2025","journal-title":"Infection"},{"key":"2026041509550899000_11.2.e002169.34","doi-asserted-by":"crossref","DOI":"10.2807\/1560-7917.ES.2023.28.1.2200850","article-title":"Molecular surveillance of multidrug-resistant Gram-negative bacteria in Ukrainian patients, Germany, March to June 2022","volume":"28","author":"Schultze","year":"2023","journal-title":"Euro Surveill"},{"key":"2026041509550899000_11.2.e002169.35","doi-asserted-by":"crossref","DOI":"10.2807\/1560-7917.ES.2022.27.50.2200896","article-title":"Multidrug-resistant organisms in patients from Ukraine in the Netherlands, March to August 2022","volume":"27","author":"Zwittink","year":"2022","journal-title":"Euro Surveill"},{"key":"2026041509550899000_11.2.e002169.36","doi-asserted-by":"crossref","DOI":"10.2807\/1560-7917.ES.2022.27.50.2200926","article-title":"Increase in NDM-1 and NDM-1\/OXA-48-producing Klebsiella pneumoniae in Germany associated with the war in Ukraine, 2022","volume":"27","author":"Sandfort","year":"2022","journal-title":"Euro Surveill"}],"container-title":["Trauma Surgery &amp; Acute Care Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/tsaco-2025-002169","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,15]],"date-time":"2026-04-15T16:55:19Z","timestamp":1776272119000},"score":1,"resource":{"primary":{"URL":"https:\/\/tsaco.bmj.com\/lookup\/doi\/10.1136\/tsaco-2025-002169"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4]]},"references-count":36,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,4,15]]},"published-print":{"date-parts":[[2026,4]]}},"alternative-id":["10.1136\/tsaco-2025-002169"],"URL":"https:\/\/doi.org\/10.1136\/tsaco-2025-002169","relation":{},"ISSN":["2397-5776"],"issn-type":[{"value":"2397-5776","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4]]}}}