592 Original Article
Authors
Y.-L. Wang1, Q.-H. Yu2, S.-K. Chen3, Y.-H. Wang4
Affiliations
Affiliation addresses are listed at the end of the article
Key words ▶ infection ● ▶ resistance ● ▶ dressings ● ▶ patients ●
Abstract
received 18.10.2014 accepted 30.10.2014 Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1395580 Published online: December 11, 2014 Drug Res 2015; 65: 592–596 © Georg Thieme Verlag KG Stuttgart · New York ISSN 2194-9379 Correspondence Y.-H. Wang Nursing College Changchun University of Chinese Medicine No. 1035 Boshuo Road Jingyue District Changchun Jilin 130117 China Tel.: + 86/431/8617 2194 [email protected]
▼
Background: With the rise of multidrug resistance among pathogens, especially in wound care management is of great concern. Hence, we designed to study the in-vitro activity of topical agents honey and silver against wound infection and compares silver and honey dressings used in wound care. Methods: 172 isolates from burn and surgical wounds were isolated from patients admitted to Nursing College, Changchun University Of Chinese Medicine, China during 2013–2014 are included in the study. 59 Pseudomonas, 41 E.coli, 28 S aureus, 25 Klebsiella pneumoniae, 11 Proteus, 8 Acinetobacter were isolated. Susceptibility testing for honey and silver nitrate was done using the agar dilution method. 80 patients were divided into 2 groups. Type 1 used Algivon with UMF12 honey coated dressing for 40 patients
Introduction
▼
With the rise of multidrug resistance among pathogens, especially in wound care management is of great concern. Due to colonization with resistant bacteria the management of wounds, gets complicated more and more leaving us with limited therapeutic options. Topical therapy plays an essential role in controlling of wound infections most importantly in overcoming the harmful effects of the bacteria in certain conditions [1]. Honey and silver has been used to treat wounds for centuries as a traditional topical agent with less toxicity [2]. With the availability of various antibiotics the use of these has been largely reduced in wound care management. With the emergence of multi drug resistance and limited therapeutic choices, the traditional topical agents are gaining importance and are being used in conventional medicine nowadays. A number of
Wang Y-L et al. Honey and Silver in Wound Care … Drug Res 2015; 65: 592–596
and the other 40 patients received Type II used Acti-coat silver absorbent dressings. 30 patients received ordinary dressings were included as control group patients. Results: 50/59 (84.7 %) Pseudomonas spp, 39 (95.1 %) of E.coli and 26/28 (92.9 %) S. aureus were sensitive for silver nitrate. K. pneumoniae, Proteus spp and Acinetobacter spp showed 100 % sensitivity for silver nitrate by agar dilution method. All the isolates showed 100 % sensitivity for honey at concentration. In type I – honey coated dressings consist of 40 patients with 18 (45 %) male and 22 (55 %) female patients. Type II – silver-coated dressings consist of 40 patients with 24 (60 %) females and 16 (40 %) male patients. Conclusion: This study results showed positive efforts on improvising in wound dressings as a replacement to lower antimicrobial resistance and limit racial use of antibiotics.
topical agents with a variety of formulations are available for treating wound infections; especially silver-based formulations are the most commonly used agents [3]. The use of honey in day-to-day clinical practice is less in-spite of its common availability and effectiveness in wound dressing formulations. There are many research studies on its antimicrobial activity similar to silver. Honey is less cytotoxic compared to silver and so far no reports of resistance to honey has been reported [4, 5]. Honey also has many beneficial actions for wound care management such as i) broad spectrum of activity ii) stimulated faster healing of wound iii) gives moist environment iv) anti-inflammatory activity v) immuno-modulatory action vi) reduced oedema [6]. From the 18th century onwards, silver has been used in wound care management, especially silver nitrate for treatment of ulcers [7]. From 1960’s silver has been used in the management
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
In-vitro Activity of Honey and Topical Silver in Wound Care Management
Original Article 593
Materials and Method
▼
172 isolates from burn and surgical wounds were isolated from patients admitted to Nursing College, Changchun University Of Chinese Medicine, China during 2013–2014 are included in the study. The institutional ethical committee approved the study. The bacterial isolates included are 59 Pseudomonas spp., 41 E.coli, 28 S aureus, 25 Klebsiella pneumoniae, 11 Proteus spp., 8 Acinetobacter spp. All isolates were identified according to the standard protocol of CLSI 2013 [18]. Among E. coli and Klebsiella isolates, 28/41 E. coli isolates and 14/25 Klebsiella spp were ESBL producers. All the isolates included in the study are multi drug resistant (MDR) showed resistance to more than 3 antibiotics. 26/59 Pseudomonas spp showed carbapenam resistance and 14/28 of S aureus were Methicillin resistant Staphylococcus aureus. Pseudomonas ATCC 27853, Staphylococcus ATCC 25923, E. coli 25922 and Klebsiella 700603 were included as control strains. Susceptibility testing for the isolates towards honey and silver nitrate was done using the agar dilution method and the minimum inhibitory concentration (MIC) was determined. Manuka honey (Leptospermum scorparium, Australia) was used in our study, which was known to have high potency of inhibition and cidal activity against gram positive and gram-negative organisms. The overnight culture of these organisms was harvested in normal saline and adjusted to 0.5 Mc Farland standard were used for the susceptibility testing. Silver nitrate (Sigma Aldrich Ltd) in the concentration of 200–1 000 µg/ml was used. 1ml of topical agents were mixed with molten Mueller Hinton agar (Oxoid laboratories) after it cooled to 45 °C 20 ml was poured into 100 mm sterile Petri plates. Plates without the topical agents served as control.
In-vitro susceptibility testing Agar-dilution method for silver
The agar dilution method for silver was used as described previously [19]. 100 µl of various concentration of silver nitrate was mixed with Mueller Hinton agar and poured into sterile Petri
plates. 10 µl of 0.5 Mc Farland adjusted cultures were inoculated on the surface of the medium and incubated for 24 h at 37 °C. MIC was recorded as the lowest concentration of silver nitrate that inhibited visible growth of the test organism.
Determination of MIC for Manuka honey by Agar dilution method
The agar dilution method for honey was used as described previously [20]. Dilutions were prepared by mixing honey with sterile Mueller Hinton agar (MHA) to get different concentration ranging from 1–20 % (vol/vol). MHA plates without honey served as control. 10 µl of the test isolates were spot inoculated on the honey incorporated plates and incubated at 37 °C for 18–24 h. MIC was recorded as the lowest concentration of honey that prevented growth of the test isolates.
Silver and honey coated dressings
A total of 80 patients with wound due to burns, surgical wound, trauma wounds were included and they were divided into 40 patients in each group. Those patients who received radiation therapy for wounds and wound size less than 1.5 cm2 were excluded from the study. Type 1 used Algivon with UMF12 honey coated dressing bandages in 40 patients and the other 40 patients in Type II used Acti-coat silver absorbent dressing’s bandages. The efficacy of the dressings were evaluated based on the change in the size of the wound, time taken for wound healing, reduction in pain and odor were taken into consideration. 30 patients with wounds who attended the hospital for dressings were included as control group patients they received only ordinary dressings none of them were used with honey coated or silver coated dressings.
Statistical analysis
Statistical analysis was done using SPSS software version 21.0. Mean, standard deviation is calculated and the data were analyzed using the Mann-Whitney U test to find the change in wound size and linear regression used to analyze. Probability of significance. The Cohen’s kappa score was used for inspecting multiple wounds and the cleanliness of wounds.
Results
▼
The susceptibility ranges of all the isolates are given in ● ▶ Table 1. Out of 59 Pseudomonas spp 50 (84.7 %) showed sensitive whereas 9 (15.3 %) showed resistance to silver nitrate. Similarly E.coli 39 (95.1 %) out of 41 were sensitive only 2 (4.9 %) showed resistance. S. aureus 26 (92.9 %) out of 28 were sensitive with only 2 (7.1 %) showing resistance for silver nitrate. Both the S. aureus strain, which showed resistance, was MRSA strain. K. pneumoniae, Proteus spp and Acinetobacter spp showed 100 % sensitivity ▶ Table 1). for silver nitrate by in-vitro methods ( ● All the isolates tested for antibacterial activity against honey showed 100 % susceptibility with 0 % resistance invariable to their multi drug resistance and Methicillin resistance. All the isolates grew at concentration of 1–10 % (v/v) of the honey tested
Table 1 Susceptibility of Silver and Honey to bacterial isolates. Topical agents
Pseudomonas (N = 59) E.coli (N = 41)
S.aureus (N = 28)
K.pneumoniae (N = 25)
Proteus (N = 11)
Acinetobacter (N = 8)
Silver Nitrate Honey
50 (84.7 %) 59 (100 %)
26 (92.9 %) 28 (100 %)
25 (100 %) 25 (100 %)
11 (100 %) 11 (100 %)
8 (100 %) 8 (100 %)
39 (95.1 %) 41 (100 %)
Wang Y-L et al. Honey and Silver in Wound Care … Drug Res 2015; 65: 592–596
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
of wounds, especially in burn patients in 0.5 % silver nitrate (AgNo3) concentration [8, 9]. Silver is known to have a broad spectrum of antimicrobial activity against both gram positive and gram-negative organism with minimal resistance reported so far. Silver has very less side effects when used as topical therapy [10, 11]. Silver-coated dressings were known to show anti-inflammatory, antimicrobial, and antiseptic activity against various wounds [12–14]. Honey dressings were known for relieving pain and for their effective healing capacity along with cleansing, anti odor and antimicrobial properties [6, 15–17]. The goal of prophylactic topical application is to control colonization and prevent infection. Hence, our study was designed to study the in-vitro activity of topical agents honey and silver against wound infection and compares silver and honey dressings used against wound infections.
▶ Fig. 1). The ATCC controls strains used showed susceptibility ( ● range of 5–10 %.
Efficacy of two dressings
80 patients with burn wounds and other wounds admitted in the hospital were included. All the demographic details of the ▶ Table 2). The patients were collected from the hospital record ( ● wound size of more than 2.5 cm2 were included in the study. 80 patients were divided into 2 groups type I – received honey coated dressings (algivon UMF12) consist of 40 patients of which 18 ▶ Fig. 2a, b). (45 %) were male and 22 (55 %) were female patients ( ● Type II – groups are those received silver coated dressings (Acti-coat absorbent dressings) also consist of 40 patients with ▶ Fig. 3a, b). 24 (60 %) females and 16 (40 %) of male patients ( ● Various parameters such as age, gender, size of wound, duration of wound healing, pain reduction etc were compared between the 2 groups. In our study, 57.5 % were women patients. The
mean age of patients in type I were 62.4 years and in type II were 59.4 years. Mean duration of the treatment was 6.5 ± 1.4 months ▶ Table 2). and wound size 128.12 cm2 to 180.1 cm2 ( ● From our study among the in-vitro methods of susceptibility testing had significant difference between the topical agent’s silver nitrate and honey. A small percentage 7.56 % of resistance towards silver nitrate was also observed in the isolates but none of the isolates showed resistance for Manuka honey. Similarly, when 2 dressings were compared there was no significant difference observed between the honey coated and silver coated dressings in size of wound, reduction in pain and cleanliness of the wounds are the same in both groups. The reduction in size of the wounds in type I (honey-coated bandages) was 14 cm2 than 9 cm2 in type II (silver-coated dressing). When the wound size was compared no statistical significance was found (P = 0.423). The wound proportion with respect to healing and cleanliness was not significant with P = 0.122 with 95 % confidence interval. The size of the wound in control group patients were also measured which was less than 8 cm2 compared to size of wound in study group patients with honey coated and silver coated dressings.
Discussion
▼
Fig. 1 Susceptibility testing by Agar dilution method for Silver nitrate.
Table 2 various clinical characteristics of the study population. Variables Age (years) Median Sex Male Female Antibiotic treatment Yes No Duration of wounds (months) Median Size of wound (cm2) Median
a
Type I Honey
Type II Silver P-value
(N = 40)
(N = 40)
62.4
59.4
0.246
18 22
16 24
1.012
2 38 5.8
4 36 6.4
0.425
128.12
124.61
0.348
0.523
b
Wang Y-L et al. Honey and Silver in Wound Care … Drug Res 2015; 65: 592–596
A lot of controversy exist between the effectiveness of the topical agents but still the topical agents has been proved to have more beneficial effects [21]. Topical applications are most commonly used for many dermatological conditions [21]. The purpose of the study was to evaluate the in-vitro efficacy of 2 most widely used topical agents honey and silver nitrate and to know their effect when incorporated in wound dressings in the form of coatings for faster healing of wounds. In our study, the bacterial isolates against which the efficacy of the topical agents was tested are multi drug resistant pathogens. In our study, bacterial isolates such as Pseudomonas spp, E.coli, and S aureus showed resistance to silver nitrate 15 %, 4.87 %, and 7.69 % respectively, this coincides with other reports of resistance for silver [22–24]. The effect of antibacterial efficacy of honey is under valuated especially in clinical practice [25]. There is much evidence on the efficacy of Manuka honey against the wound pathogens. In our study, none of the pathogens showed resistance against honey. Treatments with honey and honeybased preparations have been preferred compared to silver due to lack of toxicity in honey than in silver [4]. Our study also compared the effect of honey-coated dressings with silver-coated dressings with respect to wound size, pain, cleanliness of wounds etc. The wound size reduces upto 59 % with 52 % improvements in cleanliness of the wounds was observed when honey-coated dressings was used where as sil-
Fig. 2 Efficacy of Silver coated dressings a Before silver coated dressings b After continues use of Silver coated dressings.
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594 Original Article
Original Article 595
b
ver-coated dressings wound reduction was upto 63 % with 56 % improvement in cleanliness of wounds [26, 27]. Honey-coated and silver-coated dressings used in chronic wound treatment has proved to be effective in healing wound with reduced pain [28]. The honey-coated bandages are cost effective compared to silver-coated bandages. Silver-coated dressings show good antimicrobial activity but they have few cytotoxic effect than honey [4, 29, 30]. An Cochrane study reports honey to be superior for usage in dressing materials which coincides with our study showing high effectiveness of honey in-vitro and honey-coated dressings compared to silver nitrate and silver-coated dressings [31]. Though Honey is effective for curing of wounds there are some uncomfortness which patients has to bear like stickiness of the honey, increase in pain due to release of ions in silver coated bandages and in case of honey due to release of acid content of honey which may stimulate pain in patients [32, 33]. To conclude from our in-vitro study the use of honey and silver nitrate against multi drug resistant pathogens seems to be very effective. The use of these agents in dressings plays a vital role in healing process of wounds. From our study few differences was only noted between honey and silver dressings especially in reduction of wound size and pain. This study results showed positive efforts on improvising in wound dressings as a replacement to lower antimicrobial resistance and limit racial use of antibiotics.
Conflicts of Interest
▼
The authors declare no conflicts of interest. Affiliations 1 Department of Intensive Care Unit, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, China 2 Department of Surgery, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, China 3 Department of Nephrology, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, China 4 Nursing College, Changchun University of Chinese Medicine, Changchun, China
Fig. 3 Efficacy of Honey coated dressings a before honey coated dressings b after continues use of honey coated dressings.
References
1 Dale RM, Schnell G, Wong JP. Therapeutic efficacy of Nubiotics against burn wound infection by Pseudomonas aeruginosa. Antimicrob Agents Chemother 2004; 48: 2918–2923 2 Blair SE, Cokcetin NN, Harry EJ et al. The unusual antibacterial activity of medical-grade leptospermum honey: antibacterial spectrum, resistance, and transcriptome analysis. Eur J Clin Microbiol Infect Dis 2009; 28: 1199–1208 3 Leaper D. An overview of the evidence on the efficacy of silver dressings: In The silver Debate: a new consensus on what constitutes credible and attainable evidence. J Wound Care supplement 2011; 4 DuToit DF, Page BJ. An in-vitro evaluation of the cell toxicity of honey and silver dressings. J Wound Care 2009; 18: 383–389 5 Cooper RA, Jenkins L, Henriques AFM et al. Absence of bacterial resistance to medical grade manuka honey. Eur J Clin Microbiol Infect Dis 2010; 29: 1237–1241 6 Molan P, White R, Cooper R. Mode of action in Honey: A Modern Wound Management Product. Wounds 2005; 1–23 7 Chopra I. The increasing use of silver based products as antimicrobial agents: A useful development or a cause for concern. J Antimicrob Chemother 2007; 59: 587–590 8 Price WR, Wood M. Silver nitrate burn dressing. Treatment of seventy burned persons. Am J Surg 1966; 112: 674–680 9 Moyer CA, Brentano L, Gravens DL et al. Treatment of large human burns with 0.5 percent silver nitrate solution. Arch Surg 1965; 90: 812–867 10 Lansdown AB. Silver toxicity in mammals and how its products aid wound repair. J Wound Care 2002; 11: 173–177 11 Marshall JP, Schneider RP. Systemic argyria secondary to topical silver nitrate. Arch Dermato 1977; 113: 1077–9 12 Fong J, Wood F. Nanocrystalline silver dressings in wound management: a review. Int J Nanomedicine 2006; 1: 441–449 13 Jørgensen B, Bech-Thomsen B, Grenov B et al. Effects of a new silver dressing on chronic venous leg ulcers with signs of critical colonization. J Wound Care 2006; 15: 97–100 14 Palfreyman SJ, Nelson EA, Lochiel R et al. Dressings for healing venous leg ulcers. Cochrane Database Syst Rev 2006; 3: CD001103 15 Jull A, Walker N, Parag V et al. Randomized clinical trial of honeyimpregnated dressings for venous leg ulcers. Br J Surg 2008; 95: 175–182 16 Molan PC. Debridement of wound with honey. J Wound Technol 2009; 5: 12–17 17 Van der Weyden EA. Treatment of a venous leg ulcer with a honey alginate dressing. Br J Community Nurs 2005; 10: S21, S24, S26–S27 18 Performance standards for antimicrobial susceptibility testing – 11th informational supplement. M100-S23. CLSI, Wayne, PA, USA 2013; 19 Nakahara H, Ishikawa T, Sarai Y et al. Frequency of heavy-metals resistance in bacteria from patient in Japan. Nature 1977; 266: 165–167
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a
596 Original Article 28 Gethin G, Cowman S. Manuka honey Vs. hydrogel: a prospective, open label, multicentre, randomized controlled trial to compare desloughing efficacy and healing outcome in venous ulcers. J Clin Nurs 2008; 18: 466–478 29 Aramwit P, Muangman P, Namviriyachote N et al. In vitro evaluation of the antimicrobial effectiveness and moisture binding properties of wound dressings. Int J Mol Sci 2010; 11: 2864–2874 30 Bradshaw CE. An in vitro comparison of the antimicrobial activity of honey, iodine and silver wound dressings. Bio Horizons 2011; 4: 61–70 31 Jull AB, Walker N, Deshpande S. Honey as a topical treatment for wounds. Cochrane Database Syst Rev 2013; 2: CD005083 32 Molan P, Betts J. Using honey dressings: the practical considerations. Nurs Times 2000; 96: 36–37 33 Molan PC. The evidence supporting the use of honey as a wound dressing. Int J Low Extrem Wounds 2006; 5: 40–54
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20 Cooper RA, Molan PC, Halas E. Efficacy of honey in inhibiting strains of Pseudomonas aeruginosa from infected burns. J Burn Care Rehabil 2002; 23: 366–370 21 McRipley JR, Witney RR. Responsiveness of experimental surgical wound infections to topical chemotherapy. Antimicrob Agents Chemother 1976; 10: 45–51 22 Modak SM, Fox CL. Sulphadiazine silver-resistant Pseudomonas in burns. New topical agents. Arch Surg 1981; 116: 854–857 23 O’Meara SO, Cullum N, Majid M et al. Systematic review of wound care management: Antimicrobial agents. HealthTechnol Assess 2000; 4: 1–237 24 O’Meara SO, Cullum N, Majid M et al. Systematic review of antimicrobial agents used for chronic wounds. Br J Surg 2001; 88: 4–21 25 Molan P. The evidence and the rationale for the use of honey as a wound dressing. Wound Practice and Research 2011; 19: 204–220 26 Selby T. Managing exudate in malignant fungating wounds and solving problems for patients. Nurs Times 2009; 105: 14–17 27 Alexander S. Malignant fungating wounds: managing malodour and exudate. J Wound Care 2009; 18: 374–382
Wang Y-L et al. Honey and Silver in Wound Care … Drug Res 2015; 65: 592–596
Authors
Y.-L. Wang1, Q.-H. Yu2, S.-K. Chen3, Y.-H. Wang4
Affiliations
Affiliation addresses are listed at the end of the article
Key words ▶ infection ● ▶ resistance ● ▶ dressings ● ▶ patients ●
Abstract
received 18.10.2014 accepted 30.10.2014 Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1395580 Published online: December 11, 2014 Drug Res 2015; 65: 592–596 © Georg Thieme Verlag KG Stuttgart · New York ISSN 2194-9379 Correspondence Y.-H. Wang Nursing College Changchun University of Chinese Medicine No. 1035 Boshuo Road Jingyue District Changchun Jilin 130117 China Tel.: + 86/431/8617 2194 [email protected]
▼
Background: With the rise of multidrug resistance among pathogens, especially in wound care management is of great concern. Hence, we designed to study the in-vitro activity of topical agents honey and silver against wound infection and compares silver and honey dressings used in wound care. Methods: 172 isolates from burn and surgical wounds were isolated from patients admitted to Nursing College, Changchun University Of Chinese Medicine, China during 2013–2014 are included in the study. 59 Pseudomonas, 41 E.coli, 28 S aureus, 25 Klebsiella pneumoniae, 11 Proteus, 8 Acinetobacter were isolated. Susceptibility testing for honey and silver nitrate was done using the agar dilution method. 80 patients were divided into 2 groups. Type 1 used Algivon with UMF12 honey coated dressing for 40 patients
Introduction
▼
With the rise of multidrug resistance among pathogens, especially in wound care management is of great concern. Due to colonization with resistant bacteria the management of wounds, gets complicated more and more leaving us with limited therapeutic options. Topical therapy plays an essential role in controlling of wound infections most importantly in overcoming the harmful effects of the bacteria in certain conditions [1]. Honey and silver has been used to treat wounds for centuries as a traditional topical agent with less toxicity [2]. With the availability of various antibiotics the use of these has been largely reduced in wound care management. With the emergence of multi drug resistance and limited therapeutic choices, the traditional topical agents are gaining importance and are being used in conventional medicine nowadays. A number of
Wang Y-L et al. Honey and Silver in Wound Care … Drug Res 2015; 65: 592–596
and the other 40 patients received Type II used Acti-coat silver absorbent dressings. 30 patients received ordinary dressings were included as control group patients. Results: 50/59 (84.7 %) Pseudomonas spp, 39 (95.1 %) of E.coli and 26/28 (92.9 %) S. aureus were sensitive for silver nitrate. K. pneumoniae, Proteus spp and Acinetobacter spp showed 100 % sensitivity for silver nitrate by agar dilution method. All the isolates showed 100 % sensitivity for honey at concentration. In type I – honey coated dressings consist of 40 patients with 18 (45 %) male and 22 (55 %) female patients. Type II – silver-coated dressings consist of 40 patients with 24 (60 %) females and 16 (40 %) male patients. Conclusion: This study results showed positive efforts on improvising in wound dressings as a replacement to lower antimicrobial resistance and limit racial use of antibiotics.
topical agents with a variety of formulations are available for treating wound infections; especially silver-based formulations are the most commonly used agents [3]. The use of honey in day-to-day clinical practice is less in-spite of its common availability and effectiveness in wound dressing formulations. There are many research studies on its antimicrobial activity similar to silver. Honey is less cytotoxic compared to silver and so far no reports of resistance to honey has been reported [4, 5]. Honey also has many beneficial actions for wound care management such as i) broad spectrum of activity ii) stimulated faster healing of wound iii) gives moist environment iv) anti-inflammatory activity v) immuno-modulatory action vi) reduced oedema [6]. From the 18th century onwards, silver has been used in wound care management, especially silver nitrate for treatment of ulcers [7]. From 1960’s silver has been used in the management
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
In-vitro Activity of Honey and Topical Silver in Wound Care Management
Original Article 593
Materials and Method
▼
172 isolates from burn and surgical wounds were isolated from patients admitted to Nursing College, Changchun University Of Chinese Medicine, China during 2013–2014 are included in the study. The institutional ethical committee approved the study. The bacterial isolates included are 59 Pseudomonas spp., 41 E.coli, 28 S aureus, 25 Klebsiella pneumoniae, 11 Proteus spp., 8 Acinetobacter spp. All isolates were identified according to the standard protocol of CLSI 2013 [18]. Among E. coli and Klebsiella isolates, 28/41 E. coli isolates and 14/25 Klebsiella spp were ESBL producers. All the isolates included in the study are multi drug resistant (MDR) showed resistance to more than 3 antibiotics. 26/59 Pseudomonas spp showed carbapenam resistance and 14/28 of S aureus were Methicillin resistant Staphylococcus aureus. Pseudomonas ATCC 27853, Staphylococcus ATCC 25923, E. coli 25922 and Klebsiella 700603 were included as control strains. Susceptibility testing for the isolates towards honey and silver nitrate was done using the agar dilution method and the minimum inhibitory concentration (MIC) was determined. Manuka honey (Leptospermum scorparium, Australia) was used in our study, which was known to have high potency of inhibition and cidal activity against gram positive and gram-negative organisms. The overnight culture of these organisms was harvested in normal saline and adjusted to 0.5 Mc Farland standard were used for the susceptibility testing. Silver nitrate (Sigma Aldrich Ltd) in the concentration of 200–1 000 µg/ml was used. 1ml of topical agents were mixed with molten Mueller Hinton agar (Oxoid laboratories) after it cooled to 45 °C 20 ml was poured into 100 mm sterile Petri plates. Plates without the topical agents served as control.
In-vitro susceptibility testing Agar-dilution method for silver
The agar dilution method for silver was used as described previously [19]. 100 µl of various concentration of silver nitrate was mixed with Mueller Hinton agar and poured into sterile Petri
plates. 10 µl of 0.5 Mc Farland adjusted cultures were inoculated on the surface of the medium and incubated for 24 h at 37 °C. MIC was recorded as the lowest concentration of silver nitrate that inhibited visible growth of the test organism.
Determination of MIC for Manuka honey by Agar dilution method
The agar dilution method for honey was used as described previously [20]. Dilutions were prepared by mixing honey with sterile Mueller Hinton agar (MHA) to get different concentration ranging from 1–20 % (vol/vol). MHA plates without honey served as control. 10 µl of the test isolates were spot inoculated on the honey incorporated plates and incubated at 37 °C for 18–24 h. MIC was recorded as the lowest concentration of honey that prevented growth of the test isolates.
Silver and honey coated dressings
A total of 80 patients with wound due to burns, surgical wound, trauma wounds were included and they were divided into 40 patients in each group. Those patients who received radiation therapy for wounds and wound size less than 1.5 cm2 were excluded from the study. Type 1 used Algivon with UMF12 honey coated dressing bandages in 40 patients and the other 40 patients in Type II used Acti-coat silver absorbent dressing’s bandages. The efficacy of the dressings were evaluated based on the change in the size of the wound, time taken for wound healing, reduction in pain and odor were taken into consideration. 30 patients with wounds who attended the hospital for dressings were included as control group patients they received only ordinary dressings none of them were used with honey coated or silver coated dressings.
Statistical analysis
Statistical analysis was done using SPSS software version 21.0. Mean, standard deviation is calculated and the data were analyzed using the Mann-Whitney U test to find the change in wound size and linear regression used to analyze. Probability of significance. The Cohen’s kappa score was used for inspecting multiple wounds and the cleanliness of wounds.
Results
▼
The susceptibility ranges of all the isolates are given in ● ▶ Table 1. Out of 59 Pseudomonas spp 50 (84.7 %) showed sensitive whereas 9 (15.3 %) showed resistance to silver nitrate. Similarly E.coli 39 (95.1 %) out of 41 were sensitive only 2 (4.9 %) showed resistance. S. aureus 26 (92.9 %) out of 28 were sensitive with only 2 (7.1 %) showing resistance for silver nitrate. Both the S. aureus strain, which showed resistance, was MRSA strain. K. pneumoniae, Proteus spp and Acinetobacter spp showed 100 % sensitivity ▶ Table 1). for silver nitrate by in-vitro methods ( ● All the isolates tested for antibacterial activity against honey showed 100 % susceptibility with 0 % resistance invariable to their multi drug resistance and Methicillin resistance. All the isolates grew at concentration of 1–10 % (v/v) of the honey tested
Table 1 Susceptibility of Silver and Honey to bacterial isolates. Topical agents
Pseudomonas (N = 59) E.coli (N = 41)
S.aureus (N = 28)
K.pneumoniae (N = 25)
Proteus (N = 11)
Acinetobacter (N = 8)
Silver Nitrate Honey
50 (84.7 %) 59 (100 %)
26 (92.9 %) 28 (100 %)
25 (100 %) 25 (100 %)
11 (100 %) 11 (100 %)
8 (100 %) 8 (100 %)
39 (95.1 %) 41 (100 %)
Wang Y-L et al. Honey and Silver in Wound Care … Drug Res 2015; 65: 592–596
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
of wounds, especially in burn patients in 0.5 % silver nitrate (AgNo3) concentration [8, 9]. Silver is known to have a broad spectrum of antimicrobial activity against both gram positive and gram-negative organism with minimal resistance reported so far. Silver has very less side effects when used as topical therapy [10, 11]. Silver-coated dressings were known to show anti-inflammatory, antimicrobial, and antiseptic activity against various wounds [12–14]. Honey dressings were known for relieving pain and for their effective healing capacity along with cleansing, anti odor and antimicrobial properties [6, 15–17]. The goal of prophylactic topical application is to control colonization and prevent infection. Hence, our study was designed to study the in-vitro activity of topical agents honey and silver against wound infection and compares silver and honey dressings used against wound infections.
▶ Fig. 1). The ATCC controls strains used showed susceptibility ( ● range of 5–10 %.
Efficacy of two dressings
80 patients with burn wounds and other wounds admitted in the hospital were included. All the demographic details of the ▶ Table 2). The patients were collected from the hospital record ( ● wound size of more than 2.5 cm2 were included in the study. 80 patients were divided into 2 groups type I – received honey coated dressings (algivon UMF12) consist of 40 patients of which 18 ▶ Fig. 2a, b). (45 %) were male and 22 (55 %) were female patients ( ● Type II – groups are those received silver coated dressings (Acti-coat absorbent dressings) also consist of 40 patients with ▶ Fig. 3a, b). 24 (60 %) females and 16 (40 %) of male patients ( ● Various parameters such as age, gender, size of wound, duration of wound healing, pain reduction etc were compared between the 2 groups. In our study, 57.5 % were women patients. The
mean age of patients in type I were 62.4 years and in type II were 59.4 years. Mean duration of the treatment was 6.5 ± 1.4 months ▶ Table 2). and wound size 128.12 cm2 to 180.1 cm2 ( ● From our study among the in-vitro methods of susceptibility testing had significant difference between the topical agent’s silver nitrate and honey. A small percentage 7.56 % of resistance towards silver nitrate was also observed in the isolates but none of the isolates showed resistance for Manuka honey. Similarly, when 2 dressings were compared there was no significant difference observed between the honey coated and silver coated dressings in size of wound, reduction in pain and cleanliness of the wounds are the same in both groups. The reduction in size of the wounds in type I (honey-coated bandages) was 14 cm2 than 9 cm2 in type II (silver-coated dressing). When the wound size was compared no statistical significance was found (P = 0.423). The wound proportion with respect to healing and cleanliness was not significant with P = 0.122 with 95 % confidence interval. The size of the wound in control group patients were also measured which was less than 8 cm2 compared to size of wound in study group patients with honey coated and silver coated dressings.
Discussion
▼
Fig. 1 Susceptibility testing by Agar dilution method for Silver nitrate.
Table 2 various clinical characteristics of the study population. Variables Age (years) Median Sex Male Female Antibiotic treatment Yes No Duration of wounds (months) Median Size of wound (cm2) Median
a
Type I Honey
Type II Silver P-value
(N = 40)
(N = 40)
62.4
59.4
0.246
18 22
16 24
1.012
2 38 5.8
4 36 6.4
0.425
128.12
124.61
0.348
0.523
b
Wang Y-L et al. Honey and Silver in Wound Care … Drug Res 2015; 65: 592–596
A lot of controversy exist between the effectiveness of the topical agents but still the topical agents has been proved to have more beneficial effects [21]. Topical applications are most commonly used for many dermatological conditions [21]. The purpose of the study was to evaluate the in-vitro efficacy of 2 most widely used topical agents honey and silver nitrate and to know their effect when incorporated in wound dressings in the form of coatings for faster healing of wounds. In our study, the bacterial isolates against which the efficacy of the topical agents was tested are multi drug resistant pathogens. In our study, bacterial isolates such as Pseudomonas spp, E.coli, and S aureus showed resistance to silver nitrate 15 %, 4.87 %, and 7.69 % respectively, this coincides with other reports of resistance for silver [22–24]. The effect of antibacterial efficacy of honey is under valuated especially in clinical practice [25]. There is much evidence on the efficacy of Manuka honey against the wound pathogens. In our study, none of the pathogens showed resistance against honey. Treatments with honey and honeybased preparations have been preferred compared to silver due to lack of toxicity in honey than in silver [4]. Our study also compared the effect of honey-coated dressings with silver-coated dressings with respect to wound size, pain, cleanliness of wounds etc. The wound size reduces upto 59 % with 52 % improvements in cleanliness of the wounds was observed when honey-coated dressings was used where as sil-
Fig. 2 Efficacy of Silver coated dressings a Before silver coated dressings b After continues use of Silver coated dressings.
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594 Original Article
Original Article 595
b
ver-coated dressings wound reduction was upto 63 % with 56 % improvement in cleanliness of wounds [26, 27]. Honey-coated and silver-coated dressings used in chronic wound treatment has proved to be effective in healing wound with reduced pain [28]. The honey-coated bandages are cost effective compared to silver-coated bandages. Silver-coated dressings show good antimicrobial activity but they have few cytotoxic effect than honey [4, 29, 30]. An Cochrane study reports honey to be superior for usage in dressing materials which coincides with our study showing high effectiveness of honey in-vitro and honey-coated dressings compared to silver nitrate and silver-coated dressings [31]. Though Honey is effective for curing of wounds there are some uncomfortness which patients has to bear like stickiness of the honey, increase in pain due to release of ions in silver coated bandages and in case of honey due to release of acid content of honey which may stimulate pain in patients [32, 33]. To conclude from our in-vitro study the use of honey and silver nitrate against multi drug resistant pathogens seems to be very effective. The use of these agents in dressings plays a vital role in healing process of wounds. From our study few differences was only noted between honey and silver dressings especially in reduction of wound size and pain. This study results showed positive efforts on improvising in wound dressings as a replacement to lower antimicrobial resistance and limit racial use of antibiotics.
Conflicts of Interest
▼
The authors declare no conflicts of interest. Affiliations 1 Department of Intensive Care Unit, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, China 2 Department of Surgery, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, China 3 Department of Nephrology, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, China 4 Nursing College, Changchun University of Chinese Medicine, Changchun, China
Fig. 3 Efficacy of Honey coated dressings a before honey coated dressings b after continues use of honey coated dressings.
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