War as an evolutionary accelerator of antimicrobial resistance: environmental, clinical, veterinary, and political drivers in modern conflict zones

Authors: Laura-Madalina Lixandru, Mandi Emilia Maria Rouhiainen, Stefan Nõmmemees, Lidiia Moskalenko, Kristi Praakle, Mariia Galaburda, and Dulmini Nanayakkara Sapugahawatte

Ger. J. Microbiol. 2026. vol. 6, Iss. 3 pp:10-26
Doi: https://doi.org/10.51585/gjm.2026.3.0067

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Abstract:

Armed conflict serves as a significant evolutionary driver of antimicrobial resistance (AMR), influencing all domains of the One Health spectrum. However, its comprehensive impact is insufficiently addressed in current literature. This narrative review synthesizes 149 records (January 2005–March 2026) spanning environmental microbiology, clinical infectious disease, medical mycology, veterinary medicine, food safety, and political science, employing GRADE-adapted principles to assess the strength of evidence. Eight evidence-graded pathways underpin conflict-driven AMR: health system collapse, population displacement, informal pharmaceutical markets, water and sanitation failure, disruption of animal and food chains, cross-reservoir genomic circulation, erosion of surveillance, and toxic remnants of war. Key mechanisms include heavy-metal and hydrocarbon co-selection, blast-induced SOS responses that promote horizontal gene transfer, plastisphere biofilm formation, and farm-to-wound antifungal resistance resulting from agricultural azole use. Additionally, drug-resistant tuberculosis represents a distinct mutation-driven pathway. Conflict removes barriers between AMR reservoirs and undermines governance systems intended to control them, resulting in environmental consequences that persist for decades after hostilities end. This review examines quantitative benchmarks from recent conflicts and identifies critical research gaps. A One Health policy roadmap is proposed to incorporate AMR protection into humanitarian response, peacekeeping operations, and global health governance.

Keywords:

Antimicrobial resistance, One Health, Armed conflict, Environmental contamination, Humanitarian governance

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