By 2050, it is expected that there will be a global death toll of 10 million from infections associated with antimicrobial resistance (O'Neill, 2016). Dr Matthew Dryden – Department of Microbiology and Infection, Hampshire Hospitals NHS Foundation Trust and Rare and Imported Pathogens Department, Public Health England – told The Journal of Prescribing Practice:
‘Antimicrobial resistance is possibly the greatest threat to the future of medicine and at the moment the global problem is getting worse. We need to think of new ways of preventing and treating infection.’
The modern application of honey, an ancient remedy whose first documented use dates to 2600−2200 BC (Zubair and Aziz, 2015) is one way in which we can address this issue. Honey is a viscous, super-saturated, acidic solution (pH 3.2–4.5) comprising around 80% sugar, 20% water, antioxidants, and proteins such as the enzyme glucose oxidase (Stephen-Haynes and Callaghan, 2011). Honey works as an antibacterial in many ways: its low moisture and high sugar content helps to extract water from bacteria through osmosis; its low pH inhibits bacterial growth; and it produces hydrogen peroxide catalysed by glucose oxidase. The dilution of honey in wound exudate may cause the level of hydrogen peroxide produced to vary (Vandamme et al, 2013).
‘[Medical honeys may have] a role in surgical prophylaxis to prevent infection with multi-resistant bacteria.’
Manuka honey
Manuka honey has superior antimicrobial properties to raw honey due to its higher concentration of methylglyoxal (MGO) (Vandamme et al, 2013).
In 2004, Activon manuka honey became the first medical-grade honey to be registered as a medical device in the UK (Cooper and Gray, 2012). Medihoney – derived from manuka honey – is widely used, and its MGO is derived from nectar in the flowers of the Leptospermum scoparium tree alone. One study of 8 patients with non-healing or recurrent venous leg ulcers treated with manuka honey found that the ulcers healed with accelerated wound closure (Molan and Rhodes, 2015). Another study of 11 cases of non-healing venous ulcers unresponsive to usual treatment options, found that wounds treated with manuka honey dressings were completely closed in 3–6 weeks (Molan and Rhodes, 2015).
SurgihoneyRO
A relatively recent UK innovation is SurgihoneyRO (SHRO). Unlike manuka honey, which is sourced solely from the Leptospermum scoparium tree, SHRO (www.surgihoneyro.com) can be made from any honey – independent of floral source – that meets a European standard of being both antibiotic- and pesticide-free. Whereas manuka honey's antimicrobial activity derives mainly from MGO, SHRO's antimicrobial activity depends on a proprietary bioengineering process that ensures consistent high levels of antibacterial activity. This antibacterial activity is achieved through the prolonged release of hydrogen peroxide, and SHRO is active against both Gram-positive and Gram-negative bacteria, including multi-drug resistant strains such as MRSA, E. Coli and Pseudomonas auruginosa (Cooke et al, 2015; Halstead et al, 2016).
In a trial of caesarean section wound infection rates, Dryden et al (2014) found a 60% reduction from 5.42% before intervention, to 2.15% using SHRO; and Newby et al (2018) found SHRO to be effective at reducing non-typeable haemophilus influenzae (NTHi) biofilm viability, suggesting SHRO as an alternative to antibiotics for treating NTHi biofilm-associated infections.
Saeed et al (2017: 156) considered the problem of prosthetic joint infection, describing SHRO as
‘highly relevant for local therapy in arthroplasty with great potential for the control of bioburden and biofilm at these sites, thus providing an alternative to antibiotics, but as it is not a conventional antibiotic, it is less likely to select for resistance.’
Co-author, Mr Rhodri Llywelyn Williams – consultant orthopaedic surgeon based at BMI Werndale Hospital and Hywel Dda University NHS Health Board in Wales – told Journal of Prescribing Practice:
‘Successful treatment of prosthetic joint infection is intimately related to conquering bacteria biofilm, which attaches to the surface of a joint replacement. Honey has been used for millennia in the treatment of infections and has broad spectrum antimicrobial characteristics. We have shown honey to be safe in treating knee replacement prosthetic joint infection and I am excited by its role, fighting against the bacterial bioburden and biofilm that causes so much harm to patients.’
Dr Dryden is certain that some medical honeys, particularly the synthetic reactive oxygen products under development, can help address the challenge of antimicrobial resistance:
‘They can be used to treat open surgical and traumatic wounds, burns, chronic ulcers in the place of antibiotics, reserving these for more serious sepsis. I believe they could have a role in surgical prophylaxis to prevent infection with multi-resistant bacteria.’
Response to: Armstrong A. Prescribing in end-of-life care. Journal of Prescribing Practice. 2019; 1(6):284-288. jprp.2019.1.6.284
In response to the article on Prescribing in End of Care Life in the June issue, I would like to clarify that in most regions of the UK, the DNACPR form shown in the article is now obsolete and has been replaced by ReSPECT. It is intended that the ReSPECT document will be adopted universally across the UK in place of the DNAR record. It is already in use in most parts of the UK and is valid in all community, primary and secondary care settings.
Debate over DNAR limitations had become subject to intense ethical debate and legal challenge. (Tracey v Cambridge NHSFT, Winspear v City Hospital Sunderland NHSFT). ReSPECT has been developed by a national Working Group comprising many professional organisations including RCUK, BMA, RCGP, GMC, CQC, Royal College of Nursing and the Association of Ambulance Service Chief Executives.
ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. The ReSPECT process creates a summary of personalised recommendations for a persons clinical care in a future emergency in which they do not have capacity to make or express choices. Such emergencies are not limited to cardiac arrest, the process is intended to respect both patient preferences and clinical judgement.
For more information on the ReSPECT process, templates of the form or to access training:
- https://www.respectprocess.org.uk/
- https://respectprocess.org.uk/_pdfs/ReSPECT-Specimen-Form.pdf