Multi-drug resistant bacteria and the role of bacterial biofilms in war-related musculoskeletal infections: a narrative review.
Background: Combat-related musculoskeletal injuries often involve high-energy trauma, open fractures, and extensive soft tissue damage. These injuries are increasingly complicated by multidrug-resistant (MDR) pathogens and bacterial biofilms, which compromise clinical outcomes and increase morbidity in both military and civilian populations within conflict zones.
Objective: This narrative review synthesizes current literature to evaluate the incidence of MDR bacteria in war-related musculoskeletal infections (W-MSIs), the role of biofilms in infection persistence, and the clinical drivers of antimicrobial resistance in battlefield settings.
Key Points: Data from various conflict theaters indicate that MDR incidence in W-MSIs can reach 81% in cases of osteomyelitis. Predominant isolates include Acinetobacter baumannii, Pseudomonas aeruginosa, and Staphylococcus aureus. Biofilm formation is a critical factor in chronic infection, providing a protective niche that facilitates horizontal gene transfer and resistance to host immune responses. Identified risk factors for MDR colonization include large soft tissue defects, blast-related mechanisms of injury, and prolonged evacuation chains. Notably, evidence does not consistently support the superiority of combined antimicrobial prophylaxis over single-agent regimens. Effective management requires a multidisciplinary strategy incorporating aggressive surgical debridement, meticulous removal of necrotic bone fragments, and stringent antimicrobial stewardship.
Conclusion: The rising prevalence of MDR bacteria and biofilms in W-MSIs necessitates a shift toward targeted therapeutic interventions and rapid diagnostic protocols. Improving clinical outcomes in orthopedic trauma depends on early surgical intervention, optimized infection control, and a deeper understanding of the mechanisms driving microbial adaptation in battlefield environments.
