Patient history

An adult male dog was presented to the on-call service with a swollen mass on the medial side of the tarsal area (Figure 1, day 0). It was described as a warm and painful mass containing a fistula, and blood and pus were subsequently removed from the mass. The dog was a hunting dog and it is suspected the cause of the wound happened during one of these hunting trips. The dog had a
normal temperature (39,1℃) and a normal appetite.

Products used: L-Mesitran Soft, L-Mesitran Tulle and L-Mesitran Foam

Case study done by: Alexandra Peteoaca DVM, Faculty of Veterinary Medicine Bucharest, Romania

Methods

Upon presentation, the wound was inspected and an infection was visually confirmed by the presence of pus. Betadine was applied locally and systemic antibiotics (Amoxicillin and Clavulanic Acid) together with the NSAID Meloxicam and Tramadol were administered before administration of medical grade honey (MGH). The wound was mechanically and surgically debrided of necrotic tissue and lavaged with Ringer´s lactate until clear of all macroscopic foreign bodies. L-Mesitran Soft was used in the first 4 days of treatment and in the last 12 days of treatment; covered by non-woven gauze, cast padding, and cohesive elastic wrap. The bandage only involved the affected area, while the digital area was left unbandaged. Between the treatment with L-Mesitran Soft, L-Mesitran Tulle, and L-Mesitran Foam were applied every 2 days in an alternating pattern. Before treatment with MGH was started, the wound showed significant swelling which turned into a necrotic wound by the time of day 0. After debridement, treatment with MGH commenced.

Results

The wound had a hard mass upon presentation (Figure 1, day 0) and had to first be cleared of necrotic tissue and pus. Upon presentation, vital signs were monitored and temperature, respiratory and cardiac frequency were within normal range. Local edema was diminished. New granulation tissue was  quickly formed (Figure 1, day 3) and continued to form in the following weeks (Figure 1, days 6 and 10). Epithelialization was clearly visible (Figure 1, days 10 and 16) and the wound started to close up quickly (Figure 1, days 25 and 30), The wounds was completely closed with hair regrowth and a minimal scar on day 56 (Figure 1, day 56). The dog had no pain when handling the wound area throughout treatment and an e-collar was not needed, due to the dog tolerating the bandage very well.

Discussion

Because antibiotics (Amoxicillin and Clavulanic acid)  were administered prior to MGH treatment with little effect on resolving the infection, it might be possible a multiresistant bacterial infection was present in the wound. MGH is known to exert antimicrobial activities via multiple mechanisms, being able to eradicate (multiresistant) bacteria, even when persisting in biofilms (1-4). Since its antimicrobial activity is based on multiple mechanisms, there is no risk of the development of antimicrobial resistance (5, 6). MGH has a low pH, strong osmotic action, produces hydrogen peroxide, and holds antimicrobial constituents, all responsible for antimicrobial activity (7). Also, MGH forms a physical barrier that covers the wound and protects it from new invading pathogens. The prophylactic antimicrobial activity has recently been published in two randomized controlled studies in horses (6, 7). These studies showed a 3-times reduction in infections when MGH is applied intralesionally before primary closure of lacerations (6) and a 4-fold reduction in infections when MGH was applied subcutaneously before primary closure of colic surgeries (8). All products (L-Mesitran Soft, L-Mesitran Tulle and L-Mesitran Foam) contain 40% MGH and were used according to their intended use and function. By having different products with different functions, the benefits of MGH are not lost when a wound requires a different set of dressings. This leads to MGH being applicable to a wide array of indications.

Conclusion

MGH is capable of eradicating multiresistant bacteria via its indicated antimicrobial activity and is a good alternative to antibiotics for topical infections. At the same time, MGH stimulates wound healing, maintains a moist wound environment and leads to autolytic debridement.  

 

 

 

References

  1. Pleeging CCF, Coenye T, Mossialos D, de Rooster H, Chrysostomou D, Wagener FADTG, Cremers NAJ. Synergistic Antimicrobial Activity of Supplemented Medical-Grade Honey against Pseudomonas aeruginosa Biofilm Formation and Eradication. Antibiotics (Basel). 2020 Dec 4;9(12):866. doi: 10.3390/antibiotics9120866. PMID: 33291554; PMCID: PMC7761815.
  2. Holubová A, Chlupáčová L, Cetlová L, Cremers NAJ, Pokorná A. Medical-Grade Honey as an Alternative Treatment for Antibiotics in Non-Healing Wounds-A Prospective Case Series. Antibiotics (Basel). 2021 Jul 28;10(8):918. doi: 10.3390/antibiotics10080918. PMID: 34438968; PMCID: PMC8388796.
  3. Nair HKR, Tatavilis N, Pospíšilová I, Kučerová J, Cremers NAJ. Medical-Grade Honey Kills Antibiotic-Resistant Bacteria and Prevents Amputation in Diabetics with Infected Ulcers: A Prospective Case Series. Antibiotics (Basel). 2020 Aug 19;9(9):529. doi: 10.3390/antibiotics9090529. PMID: 32825100; PMCID: PMC7558111.
  4. Cremers NA. Something old, something new: does medical grade honey target multidrug resistance? J Wound Care. 2021 Mar 2;30(3):160-161. doi: 10.12968/jowc.2021.30.3.160. PMID: 33729849.
  5. Maddocks SE, Jenkins RE. Honey: a sweet solution to the growing problem of antimicrobial resistance? Future Microbiol. 2013;8(11):1419-29.
  1. Mandel HH, Sutton GA, Abu E, Kelmer G. Intralesional application of medical grade honey improves healing of surgically treated lacerations in horses. Equine Vet J. 2020;52(1):41-5.
  1. Renée Hermanns, Cristina Mateescu, Andreas Thrasyvoulou, Chrysoula Tananaki, Frank A.D.T.G. Wagener & Niels A.J. Cremers (2020) Defining the standards for medical grade honey, Journal of Apicultural Research, 59:2, 125-135, DOI: 1080/00218839.2019.1693713
  2. Gustafsson K, Tatz AM, Slavin RA, Dahan R, Ahmad WA, Sutton GA, et al. Will local intraoperative application of Medical Grade Honey in the incision protect against incisional infection in horses undergoing colic surgery? . AAEP Proceedings. 2019;65:387-8.