Antimicrobials – are we starting to lose the hidden battle?

Introduction

Increasing numbers of infections are caused by bacteria resistant to the antibiotics (antimicrobials) that modern medicine uses to treat them. The WHO estimates that by 2050, global deaths from antimicrobial-resistant (AMR) infections will equal cancer deaths. This is one of the most significant threats to global health. AMR is on the UK’s national risk register as a chronic threat, requiring national action. What does this mean for the military?

History & Infectious Diseases 

Since groups of warriors first formed to fight against their enemies, a hidden battle has run parallel to all military campaigns. The struggle between armies and infectious diseases can result in disaster. History is littered with examples of campaigns thwarted by outbreaks of infectious disease. Disease Non-Battle Injuries (DNBI), such as respiratory illnesses, gastroenteritis, or a variety of other tropical diseases, have been seen to cause significant harm to an army’s fighting capability.

Forces which understood the importance of hygiene and could limit the spread of infectious disease prevailed, such as during the Battle of El Alamein. Even when an army could remain healthy enough to fight, the second stage of the hidden battle began. Those lucky enough to survive the battlefield but unfortunate enough to have been injured faced a fresh battle, the fight against wound infection. So great was the risk of wounds becoming infected and gangrenous that amputation of the injured limb became a common first-line measure. Abdominal wounds and their leak of bowel contents were a death sentence. 

The Second World War and antibiotics

During the Second World War, a game-changing scientific discovery, antibiotics, was introduced to the military battlefield. The impact on treating DNBI and traumatic wounds has been significant. Despite increasingly effective weapons technology, morbidity and mortality from military-related infections remain a fraction of what it was during the pre-antibiotic era. Trauma care has evolved its focus onto managing major bleeding to save lives, as good surgical management of wounds and effective antibiotics have allowed for the salvage of injuries that would have been fatal years ago. This was evident in the numbers of unexpected survivors seen during the Iraq and Afghanistan conflicts, where the number of injured service personnel dying from wound infections was historically low. 

In the hidden battle, we have enjoyed a significant advantage, and as a result, we have become reliant on the safety net of antibiotics in military care. Pre-deployment briefs on environmental health have become a distraction to many rather than an essential component of preparation. We tend to rely on treatment rather than prevention as our ‘get out of jail free’ option for managing infectious disease outbreaks. Basic hygiene measures are not given the prominence they should, both personally and within our bases of operations. 

The rise of resistance

The enemy in the hidden battle has adapted. Bacteria started to develop resistance early after the introduction of antibiotics. This has accelerated over the last decades due to a combination of factors. The medical profession has historically overused or inappropriately prescribed antibiotics, helping drive the emergence of resistance. In many countries, antibiotics are available to buy over the counter, but they are used inappropriately and without any stewardship. The widespread use of antibiotics as a growth promoter within the agriculture industry is a significant contributor, a practice now banned in many Western nations. Countries from South America through to East Asia now have high rates of AMR within their populations. 

The threat of AMR has been compounded by a lack of new antibiotics entering medicine. Pharmaceutical companies are reluctant to spend millions on developing new drugs, only to hold them in reserve. Their infrequent use hampers any financial viability before the drug’s patent expires, and their competitors can cheaply replicate the antibiotic. 

AMR and the military

AMR infections have started to emerge within military medicine. During the recent Iraq conflict, Acinetobacter caused AMR infection in several service personnel. This became known as ‘Iraqibacter’ and contaminated the medical treatment facilities providing care.  The ongoing conflict in Ukraine demonstrates some future challenges that are manifesting today. Rates of AMR infections are far higher than in other recent conflicts. Influencing factors include delays to surgery, prolonged field care, high rates of local resistance and the medical challenges of care in austere environments. 

Military medical services have started to focus on AMR as a risk but face multiple challenges in managing this complex problem. Static and clean hospitals in the UK face challenges with AMR infections like MRSA, yet the Defence Medical Service (DMS) must operate in more austere conditions. Maximising effective infection prevention control throughout the Operational Care Pathway will be vital. Increasing numbers of patients with resistant infections will place a greater burden on the medical services in future operations. Conflicts could spread this AMR burden into the NHS hospitals used as Role 4.

The rise of AMR will increase our consideration of medical risk. The Medical Operating Concept outlines how, as the activity risk rises, consideration must be given to the sophistication and capacity of the deployed medical resources. Commanders must accept greater medical risk, increase medical support, or reduce operational demand. AMR bacteria have the potential to be used as a CBRN biological agent, and the DMS should remain alert to this threat.

Conclusion

In a ‘post-antibiotic world’, vaccination, hygiene and health protection will become central to disease prevention. Army field manuals historically contained detailed instructions on camp and personal hygiene to prevent outbreaks of disease, skills which need attention again. We must be prepared for more service personnel in the medical chain. They will require lengthier hospitalisation and potentially increased deaths from infections. AMR is a complex challenge for global health but will be an increasingly greater problem for military medicine. It requires the medical services to adjust, commanders to consider the increased risk, and everyone to understand that medicine is losing its long-held advantage in the hidden battle.

 

Main image – 16 Medical Regiment personnel on Ex SERPENT’S ANVIL (www.defenceimages.mod.uk)