Honey in the Management of Infections

Nicholas Namias

Disclosures
In This Article

Necrotizing Soft Tissue Infections

Spencer E. Efem of the University Teaching Hospital in Calabar, Nigeria, has published a series of papers on the antimicrobial and wound healing effects of honey. He first published a series of 59 patients with wounds and nonhealing ulcers, 80% of which had failed to heal with conventional therapy for periods of one month to two years[11]. He showed that wounds which initially cultured positive for a variety of organisms were sterile at one week, and that 58 of the wounds went on to heal rapidly, with separation of eschar, diminished edema, and rapid reepithelialization. His method was to apply 15-30 mL of unprocessed honey to the wound daily, after cleaning the wound with normal saline. One ulcer was due to a mycobacterial infection and did not respond to honey. Although Efem did not provide data to support the following impressions, he described the effects of honey to be "debridement of wounds by a chemical or enzymatic action; absorption of oedema fluids around wounds; inactivation of bacteria; deodorization of offensive wounds; promotion of granulation tissue formation and epithelialization; and improvement of nutrition." Efem noted the low pH (3.6) and hygroscopic (osmotic) effects of honey and their probable role in its antibacterial effect, but he also noted the effect of inhibine, a previously described thermolabile bactericidal substance. As mentioned earlier, hydrogen peroxide is produced by the action of glucose oxidase, and Efem considered the "inhibine" to be hydrogen peroxide, although there is not universal agreement on this[12,13]. In 1993, Efem published his experience with twenty consecutive cases of Fournier's gangrene managed with systemic antibiotics (amoxicillin/clavulanic acid and metronidazole) and topical unprocessed honey[14]. He compared these patients to 21 similar cases managed by other physicians in the same institution, in which the standard approach of surgical debridement and systemic antibiotics was used. The patients treated with honey had their wounds cleaned with saline upon presentation, then dressed with topical unprocessed honey or packed with gauze soaked in honey, with the wounds inspected and the honey reapplied daily after cleansing with normal saline. At seven days after the start of treatment all wounds were swabbed and found to be sterile, after having grown the usual expected mix of organisms recovered by a surface swab upon initial presentation. Although not analyzed statistically, there were more operations and re-operations required in the orthodox group, although the length of stay was shorter, on average, by 0.5 weeks in this group ( Table 1 ). In the group treated with honey, foul odor, edema, and discharge resolved within 1 week of the commencement of therapy, and all necrotic tissues had separated. Efem concluded that honey is superior to standard therapy and that it may revolutionize the treatment of this disease. Later reports from other authors show that some have indeed adopted honey as an adjunct in the treatment of Fournier's gangrene. Hejase et al. reported on a series of 38 patients with Fournier's gangrene, all of whom had surgical debridement and systemic antibiotics followed by topical application of unprocessed honey on gauze pads three times a day, with one death in the series. They provided neither data for the effects of honey nor controls in their series, but presented the cases as a series. They credited honey with local cleansing and improved healing of the wounds[15].

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