Abstract：
Management of locally infected heel-pressure ulcers (HPUs) remains challenging, and given the increasing occurrence of infections resistant to antibiotic therapy and patients’ unwillingness to surgery, innovative and effective approaches must be considered. Medical-grade honey (MGH) could be an alternative therapeutic approach due to its broad-spectrum antimicrobial activity and healing properties.
This study aimed to present the high effectiveness and safety of MGH for the conservative treatment of clinically infected HPUs. In this case series, we have prospectively studied three patients with local signs of infected HPUs. In all cases, HPUs persisted for more than 4 weeks, and previous treatments with topical antibiotics or antiseptic products were ineffective. All patients were at high-risk to develop HPU infection due to their advanced age , several comorbidities, and permanent immobility. All wounds were treated with MGH, leading to infection resolution within 3–4 weeks and complete wound healing without complication. Considering the failure of previous treatments and the chronic nature of the wounds, MGH was an effective treatment. MGH-based products are clinically and cost-effective for treating hard-to-heal pressure ulcers such as HPUs. Thus, MGH can be recommended as an alternative or complementary therapy in wound healing.
Keywords:
medical-grade honey, heel-pressure ulcers, infection, antibiotic resistance; wounds; wound healing
Introduction：
Pressure ulcers (PUs) are localized damage to the skin and/or underlying soft tissues caused by pressure or shear, usually over a bony prominence. Heel-pressure ulcers (HPUs) are the second most common type of PUs after the sacrum and the site where the most critical and severe PUs tend to develop. The heel is particularly vulnerable to pressure injury due to its thin skin, and lack of fat tissue and muscle for protection and cushioning. Moreover, the limited weight-bearing area of the posterior part of the heel must sustain high-pressure forces that are exerted directly over the calcaneus.
Currently, the median incidence rate of HPUs in hospitals is estimated as 17.4% and the median prevalence rate as 11.7%. The vast majority of HPUs remain superficial, involving only the skin (stage I and II) or the underlying subcutaneous tissue (stage III); and about 11% to 18% of all HPUs involve deeper tissues, such as muscle, tendon, or bone (stage IV).
Particularly burdensome for the public health systems as well as for patient’s quality of life is the management of hard-to-heal HPUs, defined as an injury of the skin that per sists for at least 4–6 weeks, which shows no tendency to heal despite the use of differenttreatment protocols. Additional aggravating factors can be the presence of different comorbidities, especially in the elderly population, such as diabetes and peripheral arterial disease, previous surgical procedures, impaired nutritional status, and mobility problems. Therefore, these patients are at a high risk to develop pressure ulcers complicated by local infection and consequently, a delay in the wound-healing process.
Clinical assessment of the wound characteristics is an important step in the selection of the appropriate treatment. Chronic ulcers can be complicated with inflammation and, therefore, microbial colonization; in addition, the early recognition of local signs and symptoms of infection is mandatory for a successful healing trajectory. A superficial increased bacterial burden is mainly characterized by wound-healing delay, moderate exudate levels, presence of debris (yellow or black necrotic tissue), and unpleasant odor from the wound . A deep infection is usually presented with large ulcer dimensions,
locally increased temperature, pain, edema, malodor, high exudate levels, and often bone exposure. Considering the increased occurrence of infections resistant to antibiotics, new and more efficient therapies are required to effectively treat locally infected HPUs.
Honey has been used for wound healing and local infections since ancient times. Medical-grade honey (MGH) is carefully selected, clean of pollutants, follows specific physicochemical characteristics, and is gamma-sterilized to guarantee its safe use for medical applications. MGH has broad-spectrum antimicrobial properties principally due to its high sugar content, which creates an osmotic gradient leading to microbial dehydration and growth inhibition. Other antimicrobial mechanisms of MGH are the acid pH, the production of low levels of hydrogen peroxide, and the release of components, such as flavonoids, methylglyoxal, and bee defensin-1, which are factors that are toxic to almost all microorganisms, but not to the healthy surrounding tissue . Another important property of the MGH is its wound-healing activity. MGH allows for effective autolytic wound debridement, leading to the removal of necrotic tissue. In addition, MGH has anti-inflammatory and antioxidative activity, creates a moist environment, and enhances the regenerative process in the wound by stimulating the formation of healthy granulation tissue and neo-epithelization. MGH speeds up healing in different types of acute and chronic wounds, including pressure ulcers.
In this prospective case series, we present our experience in the treatment of clinically infected HPUs with MGH. The aim of this study is to demonstrate the effective and safe use of MGH in high-risk elderly patients with multiple comorbidities.
Case1：
An 85-year-old female patient presented with a stage III HPU at her right foot due to prolonged immobility after hip arthroplasty (Figure 1a). Medical comorbidities included dementia, hyperlipidemia, hypertensive heart disease, and deficiency of vitamin B12 and calcium. The wound had been present for >2 months and unsuccessfully treated with neomycin sulfate topical spray. On initial evaluation, the ulcer dimensions were 5 cm in length and 5 cm in width. Local clinical signs of infection included hard necrotic eschar, low levels of exudate, pain, and delayed healing. Surgical (scalpel) debridement at the bedside was performed to remove the thick eschar. Manuka honey gel was applied directly to the wound, followed by Manuka honey dressing to ensure contact with the wound bed. Then, a secondary foam dressing was applied to absorb the secretions and offload the heel region. Wound-dressing changes were performed by the healthcare professional at the patient’s home at 48 h intervals. After 4 weeks, pain and exudate were considerably reduced, and healthy granulation tissue was evident (Figure 1b). Due to improved wound healing, dressing changes were transitioned to every 4 days. The HPU was completely healed after 17 weeks of MHG treatment without complications (Figure 1c).
Figure 1. (a) clinical findings at the initial examination, day 0 (start of MGH treatment); (b) effective debridement and healthy granulation tissue after four weeks of MGH therapy; (c) complete wound healing after 17 weeks of MGH therapy.
Case2：
An 88-year-old female patient presented with a stage III HPU at her left foot due to permanent immobility (Figure 2a). Relevant comorbidities included dementia, cerebrovascular disease, arterial hypertension, anemia, iron deficiency, and nephritis. The patient’s familiar ambient was non-compliant and severe malnutrition was noticed. Concomitant pressure ulcers were presented at the sacral–coccyx area and the tibial area bilaterally. The HPU was previously treated for 4 weeks with a povidone–iodine solution and a mupirocin-based topical cream, without clinical improvement. Upon presentation, the wound dimensions were 5 cm in length and 4 cm in width. Clinical signs of infections were the presence of a moderate amount of exudate, local hyperthermy, malodor, slough, and pain. Moreover, the wound edges were macerated and indented with a significant delay in the healing process. Local treatment was initiated with Manuka honey gel, followed by Manuka honey dressing. Then, a secondary foam dressing was applied to absorb the secretions and offload the heel region. Wound-dressing changes occurred at the patient’s home every 48 h by the healthcare professional. After 3 weeks of MGH treatment, the wound size reduced, granulation tissue was visible, the wound edges showed a normal re-epithelialization process, and clinical signs of infection disappeared (Figure 2b). Consequently, ulcer changes were extended to every 4 days. The HPU was completely healed after 12 weeks of MGH therapy (Figure 2c).
Figure 2. Case 2: (a) clinical findings at the initial examination, day 0 (start of MGH treatment); (b) reduction of the wound size with marginal re-epithelialization and granulation tissue formation after three weeks of MGH therapy; (c) complete wound healing after 12 weeks of MGH therapy.
Case3：
A 72-year-old female patient presented with a stage III HPU at her left foot due to permanent immobility associated with several comorbidities, including dementia, cerebrovascular disease, atrial fibrillation, myocardial infarction, arterial hypertension, and osteoporosis (Figure 3a). Previously, the wound was ineffectively cleansed for one month with soap and normal saline. On the initial presentation, her wound measured 5 cm in length and 5 cm in width. Local clinical signs of infection included erythema, low amount of exudate, debris, and delayed healing. Local treatment was initiated with Manuka honey gel, followed by Manuka honey dressing. Then, a secondary foam dressing was applied to absorb the secretions and offload the heel region. Wound-dressing changes were performed by the patient at home every 48 h intervals. At her 3-week followup, necrotic tissue was eliminated due to the osmotic property of the MGH products, the wound defect reduced considerably in size, and erythema disappeared (Figure 3b). Treatment was continued as per above, and complete healing was uneventfully achieved after 8 weeks (Figure 3c)
Figure 3. Case 3: (a) clinical findings at the initial examination, day 0 (start of MGH treatment); (b) progression of wound healing after three weeks of MGH therapy; (c) complete wound healing after 8 weeks of MGH therapy.
Conclusion:
In the present case series, MGH-based products improved the clinical outcome of hard-to-heal HPUs in elderly patients with multiple and severe comorbidities. MGH is a safe and effective therapeutic approach for locally clinical infected HPUs, and can be proposed as an alternative or complementary to antibiotics and surgery. Furthermore, MGH-based products are easy to apply at home and are cost-effective. This will lead to improving the patient’s quality of life.
Reference：
Papanikolaou, Georgios E., Georgios Gousios, and Niels AJ Cremers. "Use of Medical-Grade Honey to Treat Clinically Infected Heel Pressure Ulcers in High-Risk Patients: A Prospective Case Series." Antibiotics 12.3 (2023): 605.
