Conflict wounds and antimicrobial resistance: a systematic review on local antimicrobials to prevent infection after extremity open fracture
File(s)
Published online version
Author(s)
Type
Journal Article
Abstract
Introduction Contemporary conflict-associated injuries with open fractures are challenged by infection and antimicrobial resistance (AMR), compromising empiric antimicrobials and limiting options for systemic treatment. Local antimicrobials in high concentrations may offer an adjunctive therapy but the evidence and its relevance to conflict settings are unclear.
Methods A systematic review was undertaken using the Medline, Embase and Cochrane databases, searching for evidence relating to the use of local antimicrobials to prevent infection after extremity open fracture. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The review considered evidence for the effect of local antimicrobials across different agents, different causes of infection, AMR and adverse effects. Available evidence was considered in the context of its relevance to conflict injuries and priority research gaps were identified.
Results No studies were identified in conflict or humanitarian settings. Seven civilian systematic reviews and meta-analyses considering different outcomes and four randomised controlled trials (RCTs) were identified. There was low-quality evidence for a reduction in infection when using prophylactic local antimicrobials in addition to systemic antimicrobials, and there was no evidence of adverse outcomes. Evidence skewed towards use for Gram-positive infections. There was a lack of level one evidence and marked heterogeneity across study designs.
Conclusion AMR has emerged as a major challenge for the management of open fractures sustained in conflict. There is an urgent requirement to identify alternative treatment options and adjuncts. Local antimicrobials and biomaterials present potential opportunities. Further evidence from RCTs is required across all settings. In the context of conflict, this must include relevant outcomes, including the impact of delayed surgery, wound contamination and AMR.
Methods A systematic review was undertaken using the Medline, Embase and Cochrane databases, searching for evidence relating to the use of local antimicrobials to prevent infection after extremity open fracture. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The review considered evidence for the effect of local antimicrobials across different agents, different causes of infection, AMR and adverse effects. Available evidence was considered in the context of its relevance to conflict injuries and priority research gaps were identified.
Results No studies were identified in conflict or humanitarian settings. Seven civilian systematic reviews and meta-analyses considering different outcomes and four randomised controlled trials (RCTs) were identified. There was low-quality evidence for a reduction in infection when using prophylactic local antimicrobials in addition to systemic antimicrobials, and there was no evidence of adverse outcomes. Evidence skewed towards use for Gram-positive infections. There was a lack of level one evidence and marked heterogeneity across study designs.
Conclusion AMR has emerged as a major challenge for the management of open fractures sustained in conflict. There is an urgent requirement to identify alternative treatment options and adjuncts. Local antimicrobials and biomaterials present potential opportunities. Further evidence from RCTs is required across all settings. In the context of conflict, this must include relevant outcomes, including the impact of delayed surgery, wound contamination and AMR.
Date Issued
2026-06-02
Date Acceptance
2026-05-15
Citation
BMJ Military Health, 2026
ISSN
2633-3767
Publisher
BMJ Publishing Group
Journal / Book Title
BMJ Military Health
Copyright Statement
© Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY. Published by BMJ Group. https://creativecommons.org/licenses/by/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
License URL
Identifier
10.1136/military-2026-003255
Publication Status
Published online
Date Publish Online
2026-06-02