Epidemics of Antimicrobial Resistance in Conflict Areas: Representative Recent Examples from the Middle East and Ukraine: The Time for Action Is Now

Antimicrobial resistance (AMR) has become a pressing global health concern, and its impact is magnified in the setting of armed conflict. Wars undermine health systems by disrupting infection prevention and control, damaging water and sanitation infrastructure, limiting access to diagnostics, and driving unregulated use of antimicrobials. Infections of war wounds typically follow a temporal pattern: gram-positive organisms dominate the early phase, whereas gram-negative pathogens increasingly complicate care in the following days. Reports consistently describe high rates of methicillin-resistant Staphylococcus aureus (MRSA), while among gram-negative bacteria, Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae are the principal multidrug-resistant agents. In the Eastern Mediterranean Region, resistance levels are among the highest recorded worldwide, with carbapenem-resistant A. baumannii and extended-spectrum β-lactamase (ESBL)–producing Enterobacterales being especially common. In Ukraine, recent analyses highlight the predominance of metallo-β-lactamases, particularly NDM in Enterobacterales and P. aeruginosa, and OXA-23/-72 in A. baumannii. Forced displacement on an unprecedented scale further accelerates the cross-border spread of resistant strains. Surveillance, however, remains patchy: laboratory capacity is frequently impaired, and available studies are heterogeneous in methods and quality, limiting accurate assessment of the burden. This review brings together evidence from recent conflicts in the Middle East and Ukraine, examining resistance trends, underlying drivers, and their implications for clinical practice. Addressing AMR in conflict requires immediate, pragmatic steps: restoration of infection control and water systems, targeted screening of high-risk patients, context-specific antimicrobial stewardship, and the development of lean but standardized surveillance systems suited to resource-limited and insecure environments.