On the morning of 20 April 2023, shrapnel shredded the abdomen of a 32-year-old Ukrainian soldier who goes by the call sign “Black.” After he was evacuated from the front, doctors stitched up a ruptured intestine, removed part of his colon, and plied him with antibiotics. But his condition remained “extremely serious,” recalls Viktor Strokous, a surgeon at Kyiv City Clinical Hospital No. 6.
Black had sky-high levels of white blood cells and other signs of sepsis, an often life-threatening infection. Tests indicated the presence of extremely drug-resistant (XDR) bacteria that proved impervious to every antibiotic doctors tried. In a last-ditch measure, they gave Black a drug combo suggested by a visiting microbiologist—and then waited anxiously to see whether it worked.
Now deep into its third year, Russia’s full-scale invasion of Ukraine has become a breeding ground for bacteria that can withstand the world’s most potent antibiotics. “It’s eye-opening just how incredibly resistant some of the bacteria coming out of Ukraine are. I haven’t seen anything like it,” says Jason Bennett, director of the Multidrug-Resistant Organism Repository and Surveillance Network at the Walter Reed Army Institute of Research (WRAIR).
Ringing alarm bells the loudest is Klebsiella pneumoniae, a pathogen that globally causes one in five deaths attributable to antimicrobial resistance (AMR). Disease detectives have cultured hypervirulent Klebsiella from Ukrainian casualties, including strains described in a paper in the December issue of the Journal of Infection that are pandrug resistant—in other words, no single antibiotic can vanquish them. “That really makes Klebsiella a red flag,” says Sarah Legare, a public health specialist based in Kyiv for ICAP, Columbia University’s global health center.
To help Ukraine fight the resistant microbes, and prevent them from spilling over its borders, European and U.S. health agencies are rushing in diagnostic equipment and training hospital staff in infection prevention. The urgency derives from the lethal threat posed by AMR—a bigger killer than HIV or malaria. In 2021, AMR was the direct cause of an estimated 1.14 million deaths worldwide and a factor in an additional 4.71 million deaths, according to a 28 September report in The Lancet compiled by the Global Burden of Disease study. By 2050, the article forecasts, AMR could contribute to 10 million deaths a year. Misuse of antibiotics is a key driver of resistance, imperiling “many of the gains of modern medicine,” the World Health Organization (WHO) recently warned.
For decades, Ukraine has been known for indiscriminate antibiotic use—and then came war. Conflict zones are notorious cradles of AMR. Bullets and shrapnel embed pathogens deep in the body, “where they find the ideal conditions to thrive,” says Scott Pallett, a physician and microbiologist at the Royal Centre for Defence Medicine. If an injured soldier can’t be evacuated quickly, medics are “more likely to give broad-spectrum antibiotics” to prevent infection, he says. Pallett says such prophylactic use of the drugs, though unavoidable, can “add fuel to the fire” by promoting the evolution and spread of genes for drug resistance.
In the killing fields of Iraq and Afghanistan in the early 2000s, the signature drug-resistant pathogen to emerge was the bacterium Acinetobacter baumannii. But although alarming, these “Iraqibacter” still succumbed to broad-spectrum antibiotics called carbapenems. Since then, however, carbapenem resistance has been gaining momentum globally. “The nastiest resistance gene floating around right now” codes for an enzyme called New Delhi metallo-beta-lactamase 1 (NDM-1), which defangs carbapenems, says WRAIR microbiologist Patrick McGann. “Pick up that one gene, and you’ve got resistance to the entire class of antibiotics.”
In Ukraine, the NDM-1 resistance gene has shown up in Klebsiella, a rod-shaped bacterium that has emerged as a singular villain. One characteristic that makes it so hardy is that compared with other bacteria, Klebsiella produces an “extraordinary” amount of mucus, says Kristian Riesbeck, a clinical microbiologist at Lund University. Thus it’s adept at forming biofilms, in which drug-resistant bacteria on the surface shield vulnerable populations deeper in the wound. According to McGann, some 80% of Klebsiella strains sequenced so far in Ukraine carry NDM-1—a rate 10 times higher than in the rest of Europe. One reason for the gene’s rapid spread: Klebsiella is adept at grabbing plasmids—extrachromosomal DNA–containing resistance genes directly from other bacteria.
