PUBH6005-Treating Bacterial Wound Infection Essay

Question:

Discuss How effective is honey at treating bacterial wound infections?

Answer:

Introduction

Substantial amount of historical evidence reported that use of honey as a treatment for wound amongst ancient Egyptians as well as for the duration of the world wars by field nurse. After the penicillin discovery and subsequent antibiotic insurgence, honey became ignored as a treatment for wound. In the year 1999, in Australia, honey was recorded as a current medical preparation for the first time. This leads to the emergence of different honey based products like sterile manuka honey tubes, dressings, and ointments. However, these were underutilized and only used as a last resort. In contrast, current emergence of antibiotic resistance bacteria or superbug have changed this scenario. Antibiotics are become ineffective against bacteria in a terrifying rate and no new group of antibiotics have not been discovered in the last three decades. Along with these, creating new antibiotics are difficult and expensive task without any guarantee of success. This prompts researchers to look for alternative way like use of honey to treat wound infection. Honey has high acidity (pH varies from 3.4 -6.1) and osmolarity (Aw: 0.6) levels (Maddocks & Jenkins, 2013). Researchers believe that this is the reason behind honey’s antimicrobial activity as it leads to inhospitable environment for many microbes (Maddocks & Jenkins, 2013). Although, artificial honeys which imitates the sugar constituent of honey have inferior antimicrobial activity in comparison with the organic honeys. Not only bacteria, but honey is effective against viruses and fungi also. Studies have shown that fifty-eight strains of coagulase positive Staphylococcus aureus isolated from infected wound were detected as sensitive to honey (Maddocks & Jenkins, 2013). Furthermore, antibiotic resistant variant like methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci have found to be vulnerable against different types of honeys at 10 per cent concentration (w/v) and below (Maddocks & Jenkins, 2013). Eighteen isolated strain of MRSA and seven vancomycin resistant enterococci were amongst them. In most of the studies which investigated the mechanism of antimicrobial actions of honey used manuka honey as its sterile preparation has been commercially available. Revamil™ and manuka honey are only two honey variants commercially available which are registered as medical device (Maddocks & Jenkins, 2013). However, there is no academic evidence for any large scale clinical trial for honey as a treatment for wound although pre- prepared honey wound dressings or tube of pure honey has been registered as medical device. Therefore, in this critical assessment, article related to the research question ‘How effective is honey at treating bacterial wound infections?’ will be assessed.

Methods

Article selection

For this critical assessment, five articles have been chosen. Three of them are review article and two of them are original research article. Focus have been given on the recent articles related to the topic. To this extent, all five articles were selected from the timeframe between 2013 and 2018.

Search database

The database that was used for the searching of the articles was ‘Google Scholar’ ( The custom range was used for the search by setting the parameters between 2013 and 2018.

Search keywords

Few keywords were used to get the articles relevant to the topic discussed in this critical assessment. Those keywords are: ‘Honey’, ‘treatment’, ‘bacterial’, and ‘infection’.

Assessment and grading tool

After that the articles were assessed and graded on their merit. Assessment tool that was used in this article is Method for Evaluating Research and Guideline Evidence (MERGE) as mentioned by Rychetnik et al. (2002). For the MERGE assessment two different criteria was used, one is descriptive information about the review or study and another is evaluation criteria. Both of these criteria were assessed using various different parameters for example type of study, outcomes and implementation methods. On the other hand, for the grading of the articles, FORM evidence based clinical guidelines have been used (Hillier et al., 2011). Five grading parameters were used to grade and assess the studies and these are evidence base, consistency, clinical impact, generalisability, and applicability to Australian healthcare. To grade these five parameters, four grading mark have been used which are excellent, good, satisfactory, and poor.

Results

Method for Evaluating Research and Guideline Evidence (MERGE) assessment tool was used to assess the articles. Assessment of the articles have been provided below:

Assessment of the article 1:

Descriptive information about the study

Description

Identification of review

Jull, A. B., Walker, N., & Deshpande, S. (2013). Honey as a topical treatment for wounds. Cochrane Database Syst Rev, 2(2).

Type of review

Systematic review

What kind of studies have been considered in the review?

Studies that are considered for this reviews are randomized controlled trials (RCTs) and quasi- randomized controlled

Trials.

Types of outcomes considered in the review

This study considered both the benefits and adverse effect of honey.

Whether interventions aimed at populations or individuals?

The interventions discussed in the paper aimed at the need of individuals.


Evaluation criteria for the review

Comments

Does the review identified all relevant studies rigorously and sufficiently?

Yes – the study reviewed relevant studies sufficiently and rigorously. All total 25 trails were considered with total 2987 subjects.

Does the review covered all the potential harms and benefits of the topic?

The review mainly discusses about the benefits of honey as wound treatment but also discuss the adverse effect of it.

Does the review include only randomised controlled trials?

No – the review also includes Quasi-randomised controlled trials

Are the data presented in a summarised fashion to provide confidence intervals and estimate of effect?

Yes – the data are presented in summarized manner for confidence interval and estimate of effect.

Are the studies considered here quality assessed?

Yes – authors have set up criteria for selection and studies which have not met the criteria were excluded.

Assessment of the article 2:

Descriptive information about the study

Description

Identification of review

Maddocks, S. E., & Jenkins, R. E. (2013). Honey: a sweet solution to the growing problem of antimicrobial resistance?. Future microbiology, 8(11), 1419-1429.

Type of review

Non systematic review

What kind of studies have been considered in the review?

Every kind of study have been considered for this review

Types of outcomes considered in the review

This review discussed the benefits of the interventions and some of the harmful effect.

Whether interventions aimed at populations or individuals?

The intervention was aimed at the population.

Evaluation criteria for the review

Comments

Does the review identified all relevant studies rigorously and sufficiently?

Yes – this review identified and consulted all the relevant studies rigorously and sufficiently.

Does the review covered all the potential harms and benefits of the topic?

No – this review mainly focussed on the benefits of the intervention and only superficially discussed the potential harms.

Does the review includes only randomised controlled trials?

No – this review considered every kind of study

Are the data presented in a summarised fashion to provide confidence intervals and estimate of effect?

No – the data were presented in a descriptive manner without any analysis.

Are the studies considered here quality assessed?

No selection criteria were set up for this review.

Assessment of the article 3:

Descriptive information about the study

Description

Identification of review

Eteraf-Oskouei, T., & Najafi, M. (2013). Traditional and modern uses of natural honey in human diseases: a review. Iranian journal of basic medical sciences, 16(6), 731.

Type of review

Non systematic review

What kind of studies have been considered in the review?

All kind of studies have been considered in this review.

Types of outcomes considered in the review

Both the adverse effect and the benefits have been discussed in this review.

Whether interventions aimed at populations or individuals?

The intervention discussed here aimed at the need of human populations


Evaluation criteria for the review

Comments

Does the review identified all relevant studies rigorously and sufficiently?

Yes – this review have discussed all the relevant studies rigorously and sufficiently.

Does the review covered all the potential harms and benefits of the topic?

Yes – this review have investigated both the benefits and potential harmful effect but the harmful effect section leaves something to be desired.

Does the review includes only randomised controlled trials?

No – this review considered and discussed every kind of study.

Are the data presented in a summarised fashion to provide confidence intervals and estimate of effect?

No – the presented data did not provide confidence intervals and estimate of effect and were presented in a descriptive manner.

Are the studies considered here quality assessed?

No – studies considered in this review were not quality assessed.

Assessment of article 4:

Descriptive information about the study

Description

Identification of study

Boekema, B. K. H. L., Pool, L., & Ulrich, M. M. W. (2013). The effect of a honey based gel and silver sulphadiazine on bacterial infections of in vitro burn wounds. Burns, 39(4), 754-759.

Type of study

Randomized controlled trials

What kind of interventions have been considered and implemented?

Honey based gel was used to treat the burn wound of human skin. Human skins were obtained by either donation or tissue bank. Bacterial culture was used to study the bacterial activity.

Is the intervention aimed at populations or individuals?

The intervention was aimed at the individuals.


Evaluation criteria for the study

Comments

Study type

Randomized control trial

Are participants of the study well defined in terms of place, person and time?

Yes – subject is well defined in the study.

Is exposure to interventions determined in a valid, reliable and standard method?

Yes – the method was standard, reliable and valid

Is exposure to interventions determined in the same way for both control and intervened groups?

Yes

Are outcomes determined in a valid, reliable and standard method?

Yes

Are outcomes determined in the same way for both control and intervened group?

Yes

Whether any factors other than intervention were considered or not?

No – no other factors other than intervention were considered.

Is the intention of the analysis were to intervene?

Yes – the intention of the analysis were to intervene.

Assessment of article 5:

Descriptive information about the study

Description

Identification of study

Noori, A. L., Al Ghamdi, A., Ansari, M. J., Al-Attal, Y., Al-Mubarak, A., & Salom, K. (2013). Differences in composition of honey samples and their impact on the antimicrobial activities against drug multiresistant bacteria and pathogenic fungi. Archives of medical research, 44(4), 307-316.

Type of study

Quasi randomized control study

What kind of interventions have been considered and implemented?

Five honey samples were collected from different location and their composition were analysed. After that samples were used to study the antimicrobial activity by treating them against microbes such as bacteria and fungi

Is the intervention aimed at populations or individuals?

Interventions were aimed at populations.


Evaluation criteria for the study

Comments

Study type

Quasi randomized control study

Are participants or parameters of the study well defined in terms of place, person and time?

Yes it is well defined.

Is exposure to interventions determined in a valid, reliable and standard method?

Yes

Is exposure to interventions determined in the same way for both control and intervened groups?

Yes

Are outcomes determined in a valid, reliable and standard method?

Yes – it is determined in valid, reliable and standard method.

Are outcomes determined in the same way for both control and intervened group?

Yes

Whether any factors other than intervention were considered or not?

Yes – composition of honey were analysed.

Is the intention of the analysis were to intervene?

Yes – the intention of the analysis were to intervene.

FORM matrix and evidence body

Grading assessment of the five chosen articles have been described below:

Review or

Component

Study

Evidence base

Consistency

Clinical impact

Generaliz-ability

Applicability

Jull, Walker & Deshpande, 2013

Excellent

Excellent

Good

Excellent

Excellent

Maddocks & Jenkins, 2013

Satisfactory

Satisfactory

Good

Good

Excellent

Eteraf-Oskouei & Najafi, 2013

Satisfactory

Good

Good

Good

Excellent

Boekema & Ulrich, 2013

Good

Good

Good

Good

Excellent

Noori et al., 2013

Good

Good

Good

Good

Excellent

Discussion

To summarize the above result section, it can be inferred that all the review and studies were investigating the effect of honey as topical treatment and its efficacy in wound treatment and antimicrobial activity due to the recent rise drug resistant microbes or superbug. Jull, Walker & Deshpande (2013) have reviewed the use of honey as a topical treatment and its use in treating wounds. They have concluded that honey might be effective in comparison with conventional dressings but there is considerable amount of uncertainty regarding the acceptability and replicability of this evidence. On the other hand, Maddocks & Jenkins (2013) have investigated the merit of honey as a solution to the growing problem of antimicrobial resistance. They have reported in their study that manuka honey have strong antimicrobial property. On the contrary, Eteraf-Oskouei & Najafi (2013) have investigated honey in a broad view reported its traditional and modern uses. Similar like previous two reviews, they have also reported various benefits of honey which can be used to treat various human diseases. Boekema & Ulrich (2013) have used honey based gel to treat the bacterial infection of in vitro burn wounds. In their study, they reported that, honey based gel can be effective alternative for traditional treatments and can be applied in higher frequency. Additionally, Noori et al., (2013) have investigated the differences in various honey composition along with their antimicrobial activities towards drug resistant bacteria and pathogenic fungi. Similar like Boekema & Ulrich (2013), they have also suggested that honey can be used as a alternative treatment methods against drug resistant microbes. However, from the assessment and grading described in result section, it can be seen that quality of the all the paper are not same and Jull, Walker & Deshpande (2013) have published the highest quality of research as its secured the highest grading regarding the parameters. Papers published by Boekema & Ulrich (2013) and Noori et al., (2013) are also closely behind in quality. All of the paper reported the effectiveness of honey as a substitute to antimicrobial treatment and there is already pre-prepared honey wound dressings is available in the market. Therefore, honey can be implemented as a treatment to various hospitals and treatment centres as alternative to reduce the risk of drug resistant microbes. Multiple studies have reported to the effectiveness of the honey, but very little or no researches have been dedicated to large scale, robust clinical trials of honey in healthcare. Further research is needed in this area to reduce gap or limitation whether honey can be used in healthcare as topical treatment.

Conclusion

Therefore, from the above discussion, it can be concluded that honey has the potential to be used as topical treatment to battle bacterial wound infections. Multiple researches have been performed in this area and all of them reported that honey has antimicrobial activity. However, effectiveness of the honey can be varying on the type and location of the harvested area. Additionally, there is no evidence of large scale clinical trial of honey as an alternative treatment despite few honey wound dressing available commercially as registered medical device. Hence, further research and government support is needed to make honey as an alternative treatment for bacterial wound infections

References

Boekema, B. K. H. L., Pool, L., & Ulrich, M. M. W. (2013). The effect of a honey based gel and silver sulphadiazine on bacterial infections of in vitro burn wounds. Burns, 39(4), 754-759.

Eteraf-Oskouei, T., & Najafi, M. (2013). Traditional and modern uses of natural honey in human diseases: a review. Iranian journal of basic medical sciences, 16(6), 731.

Hillier, S., Grimmer-Somers, K., Merlin, T., Middleton, P., Salisbury, J., Tooher, R., & Weston, A. (2011). FORM: an Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BMC medical research methodology, 11(1), 23.

Jull, A. B., Walker, N., & Deshpande, S. (2013). Honey as a topical treatment for wounds. Cochrane Database Syst Rev, 2(2).

Maddocks, S. E., & Jenkins, R. E. (2013). Honey: a sweet solution to the growing problem of antimicrobial resistance?. Future microbiology, 8(11), 1419-1429.

Noori, A. L., Al Ghamdi, A., Ansari, M. J., Al-Attal, Y., Al-Mubarak, A., & Salom, K. (2013). Differences in composition of honey samples and their impact on the antimicrobial activities against drug multiresistant bacteria and pathogenic fungi. Archives of medical research, 44(4), 307-316.

Rychetnik, L., Frommer, M., Hawe, P., & Shiell, A. (2002). Criteria for evaluating evidence on public health interventions. Journal of Epidemiology & Community Health, 56(2), 119-127.

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