The emergence of MDR organisms is a major problem facing both military and civilian facilities handling causalities of war. Increasing bacterial resistance in conflict injuries has been described in previous wars including the Vietnamese and Korean wars [50–52, 57]. More recently, the first carbapenemase-producing K. pneumonia ST11 in Ukraine was reported from a patient injured during the Maidan revolution [58].

The free movement of injured fighters and civilians has facilitated the transmission of MDR pathogens. Nosocomial transmission has been reported to be a greater contributing factor to wound infection over environmental contamination at the time of injury [59–61]. For this reason, strict infection control practices and techniques must be implemented to reduce nosocomial transmission of MDR organisms. They include patient contact isolation upon admission, hand hygiene, wearing of gloves when in contact patients, masks and eye protection as needed, avoiding unnecessary empiric use of broad-spectrum antibiotics, and limiting the duration of antibiotic administration. The use of local antibiograms is encouraged, as it is helpful in assessing local epidemiology and antibiotic resistance. Separation of patients as per length of hospital stay (longer or shorter than 72 h) should be encouraged [54].

The use of prophylactic antibiotics in war-related trauma is common practice despite being a subject of significant controversy [62, 63]. Current evidence suggests that the use of broad-spectrum antimicrobial agents at the time of injury should be discouraged since it may be a potential cause of antimicrobial resistance. There is strong recommendation against the early use of aminoglycosides or fluoroquinolones to cover for gram-negative bacteria and against the early administration of penicillin to prevent gas gangrene or infections caused by Streptococci [64]. In severe trauma patients broad-spectrum antibiotic coverage against MDR pathogens is not needed at the time of injury and the administration of antimicrobials for more than 24 h do not affect mortality or confer additional protection against serious infectious complications including sepsis. It is believed that prolonged administration of broad spectrum antibiotics increases the probability of infection with MDR pathogens [62, 63].

The Infectious Disease Society of America (IDSA) and the Surgical Infection Society (SIS) produced joint guidelines for the prevention of infections associated with combat-related injuries. These guidelines advocate the administration of systemic antibiotics within 3 h following injury to prevent infectious complications including sepsis. The choice of antibiotics depends on the location of the wound with Cefazolin (first-generation cephalosporin) being preferred in the extremity, central nervous system, and thoracic wounds, while metronidazole (an antimicrobial with anti-anaerobic activity) to be used in abdominal wounds. Topical agents such as silver sulfadiazine and mafenide acetate are suggested for burn trauma patients [64]. Other guidelines have similar recommendations [54, 65]. The French Armed Forces recommend the use of 2 g of amoxicillin–clavulanic acid intravenously 3 times daily for all injuries as first-line antibiotic prophylaxis. Gentamicin 400 mg once-daily dose for 3 days is added for gram-negative coverage in type III open fracture (particularly, type IIIb and IIIc) and abdominal trauma with perforation of a hollow viscera [66]. Table 19.2 describes the various recommendations for antibiotic prophylaxis as suggested by the IDSA/SIS, French military, and Petersen and Waterman review in penetrating combat-related trauma [64–66].