Jim Kling

May 20, 2013

ISTANBUL, Turkey — A sterilized honey preparation was effective in preventing infections at the site of peritoneal dialysis catheters, according to a study presented here at the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) 50th Congress.

However, the honey preparation underperformed versus mupirocin in patients with diabetes, said presenter Carolyn van Eps, PhD, staff nephrologist at the Princess Alexandra Hospital, in Brisbane, Australia.

There is little evidence regarding the optimal strategy for prevention of infection in peritoneal dialysis catheters. "Honey has potential advantages," Dr. van Eps told Medscape Medical News. "A very broad range of germs are covered by honey, including gram-positive and gram-negative bacteria, and fungi, as well as multi-drug resistant organisms. And it has not been shown in any study to induce antibiotic resistance, which can be a problem with mupirocin. Honey also helps disrupt biofilms," which can develop on the surface of catheters.

The researchers conducted a multicenter, multinational, randomized control trial that included 371 patients on peritoneal dialysis. They compared standard exit-site care plus exit-site application of antibacterial honey (Medihoney Antibacterial Wound Gel, Comvita) vs intranasal mupirocin prophylaxis combined with standard exit-site care. Subjects carrying Staphylococcus aureus were equally randomized to honey (n = 40, 21.5% of honey group) and control groups (n = 41, 22.2% of control group).

The primary outcome of the study was time to first episode of any catheter-related infection. Secondary outcomes were time to individual catheter-related infections, time to coinfection-associated catheter removal, rates of catheter-related infection, occurrence of mupirocin-resistant staphylococcal isolates, serious adverse events, and death.

The researchers used an intention-to-treat analysis to analyze treatment outcomes.

Table. Honey vs Mupirocin in Preventing Infections

Outcome Intervention Control Ratio 95% Confidence Interval P Value
Median Kaplan-Meier time to first infection (months) 16.0 17.7 Hazard 1.12 0.83 – 1.51 .470
Exit-site infection rate (episodes per patient-year) 0.37 0.29 Incident 1.25 0.88 – 1.79 .220
Rates of peritonitis (episodes per patient-year) 0.42 0.42 Incident 1.00 0.73 – 1.37 .990
Mupirocin-resistant staphylococcal isolates (%) 0 7 .100
Serious adverse events 298 327 .150
Death 14 18 .900

 

In the subgroup of patients with diabetes mellitus, there was a significant difference in the honey group and the control group. There was a higher risk for the composite outcome hazard ratio (HR)1.85, 95% confidence interval (CI) 1.05 – 3.24, P = .03 and an increased risk for peritonitis HR 2.25, 95% CI 1.16 – 4.36, P = .002.

"Honey was not better and not worse compared to mupirocin. Patients with diabetes seemed to do a bit worse when we used honey compared to mupirocin, and there were more withdrawals from the trial in people who used honey, and that was due to a combination of reasons because the patients or physician wanted to withdraw, or they got a local reaction," said Dr. van Eps.

"For those reasons, honey is probably not the ideal firstline recommendation, but it probably does have a role in patients who we know have organisms that are resistant to mupirocin, or in patients who have local reactions to mupirocin," she said.

Session moderator Rosanna Coppo, MD, from Regina Margherita Children's University Hospital, in Turin, Italy, said, "It was a nice idea, because infection is a common problem in patients on dialysis, and they use mupirocin to prevent the infection. Honey is a more natural way to do it."

It had the same efficacy, Dr. Coppo told Medscape Medical News, and after a given period, there is a loss of efficacy of mupirocin. If you have the option to use one agent for 2 or 3 years and then move to the other, it's better than having only one option.

Dr. van Eps and Dr. Coppo have disclosed no relevant financial relationships.

European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) 50th Congress: Late-Breaking Clinical Trials. Presented May 19, 2013.

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