Critical Assessment of Research Articles on Honey as a Treatment for Bacterial Wound Infections

This critical assessment evaluates the effectiveness of honey as a treatment for bacterial wound infections. Five articles were chosen and assessed using the Method for Evaluating Research and Guideline Evidence (MERGE) and FORM evidence-based clinical guidelines. The assessment provides insights into the benefits and potential harms of honey as a wound treatment.

Running head: CRITICAL ASSESSMENT OF RESEARCH ARTICLES
Critical assessment of research articles
Name of the Student
Name of the University
Author Note:

1CRITICAL ASSESSMENT OF RESEARCH ARTICLES
Topic
How effective is honey at treating bacterial wound infections?
Introduction
Substantial amount of historical evidence reported that use of honey as a treatment for
wound amongst ancient Egyptians as well as for the duration of the world wars by field
nurse. After the penicillin discovery and subsequent antibiotic insurgence, honey became
ignored as a treatment for wound. In the year 1999, in Australia, honey was recorded as a
current medical preparation for the first time. This leads to the emergence of different honey
based products like sterile manuka honey tubes, dressings, and ointments. However, these
were underutilized and only used as a last resort. In contrast, current emergence of antibiotic
resistance bacteria or superbug have changed this scenario. Antibiotics are become
ineffective against bacteria in a terrifying rate and no new group of antibiotics have not been
discovered in the last three decades. Along with these, creating new antibiotics are difficult
and expensive task without any guarantee of success. This prompts researchers to look for
alternative way like use of honey to treat wound infection. Honey has high acidity (pH varies
from 3.4 -6.1) and osmolarity (Aw: 0.6) levels (Maddocks & Jenkins, 2013). Researchers
believe that this is the reason behind honey’s antimicrobial activity as it leads to inhospitable
environment for many microbes (Maddocks & Jenkins, 2013). Although, artificial honeys
which imitates the sugar constituent of honey have inferior antimicrobial activity in
comparison with the organic honeys. Not only bacteria, but honey is effective against viruses
and fungi also. Studies have shown that fifty-eight strains of coagulase positive
Staphylococcus aureus isolated from infected wound were detected as sensitive to honey
(Maddocks & Jenkins, 2013). Furthermore, antibiotic resistant variant like methicillin-
resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci have found to
be vulnerable against different types of honeys at 10 per cent concentration (w/v) and below

2CRITICAL ASSESSMENT OF RESEARCH ARTICLES
(Maddocks & Jenkins, 2013). Eighteen isolated strain of MRSA and seven vancomycin
resistant enterococci were amongst them. In most of the studies which investigated the
mechanism of antimicrobial actions of honey used manuka honey as its sterile preparation
has been commercially available. Revamil™ and manuka honey are only two honey variants
commercially available which are registered as medical device (Maddocks & Jenkins, 2013).
However, there is no academic evidence for any large scale clinical trial for honey as a
treatment for wound although pre- prepared honey wound dressings or tube of pure honey has
been registered as medical device. Therefore, in this critical assessment, article related to the
research question ‘How effective is honey at treating bacterial wound infections?’ will be
assessed.
Methods
Article selection
For this critical assessment, five articles have been chosen. Three of them are review
article and two of them are original research article. Focus have been given on the recent
articles related to the topic. To this extent, all five articles were selected from the timeframe
between 2013 and 2018.
Search database
The database that was used for the searching of the articles was ‘Google Scholar’
(https://scholar.google.co.in/). The custom range was used for the search by setting the
parameters between 2013 and 2018.
Search keywords
Few keywords were used to get the articles relevant to the topic discussed in this
critical assessment. Those keywords are: ‘Honey’, ‘treatment’, ‘bacterial’, and ‘infection’.

3CRITICAL ASSESSMENT OF RESEARCH ARTICLES
Assessment and grading tool
After that the articles were assessed and graded on their merit. Assessment tool that
was used in this article is Method for Evaluating Research and Guideline Evidence (MERGE)
as mentioned by Rychetnik et al. (2002). For the MERGE assessment two different criteria
was used, one is descriptive information about the review or study and another is evaluation
criteria. Both of these criteria were assessed using various different parameters for example
type of study, outcomes and implementation methods. On the other hand, for the grading of
the articles, FORM evidence based clinical guidelines have been used (Hillier et al., 2011).
Five grading parameters were used to grade and assess the studies and these are evidence
base, consistency, clinical impact, generalisability, and applicability to Australian healthcare.
To grade these five parameters, four grading mark have been used which are excellent, good,
satisfactory, and poor.
Results
Method for Evaluating Research and Guideline Evidence (MERGE) assessment tool
was used to assess the articles. Assessment of the articles have been provided below:
Assessment of the article 1:
Descriptive information about the
study Description
Identification of review
Jull, A. B., Walker, N., & Deshpande, S. (2013). Honey as a
topical treatment for wounds. Cochrane Database Syst
Rev, 2(2).
Type of review Systematic review
What kind of studies have been
considered in the review?
Studies that are considered for this reviews are randomized
controlled trials (RCTs) and quasi- randomized controlled
Trials.
Types of outcomes considered in
the review
This study considered both the benefits and adverse effect of
honey.
Whether interventions aimed at The interventions discussed in the paper aimed at the need of

4CRITICAL ASSESSMENT OF RESEARCH ARTICLES
populations or individuals? individuals.
Evaluation criteria for the review Comments
Does the review identified all relevant studies
rigorously and sufficiently?
Yes – the study reviewed relevant studies
sufficiently and rigorously. All total 25 trails
were considered with total 2987 subjects.
Does the review covered all the potential harms
and benefits of the topic?
The review mainly discusses about the benefits
of honey as wound treatment but also discuss
the adverse effect of it.
Does the review include only randomised
controlled trials?
No – the review also includes Quasi-randomised
controlled trials
Are the data presented in a summarised fashion
to provide confidence intervals and estimate of
effect?
Yes – the data are presented in summarized
manner for confidence interval and estimate of
effect.
Are the studies considered here quality
assessed?
Yes – authors have set up criteria for selection
and studies which have not met the criteria were
excluded.
Assessment of the article 2:
Descriptive information about the
study Description
Identification of review
Maddocks, S. E., & Jenkins, R. E. (2013). Honey: a sweet
solution to the growing problem of antimicrobial
resistance?. Future microbiology, 8(11), 1419-1429.
Type of review Non systematic review
What kind of studies have been
considered in the review? Every kind of study have been considered for this review
Types of outcomes considered in
the review
This review discussed the benefits of the interventions and
some of the harmful effect.
Whether interventions aimed at
populations or individuals? The intervention was aimed at the population.
Evaluation criteria for the review Comments

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Does the review identified all relevant studies
rigorously and sufficiently?
Yes – this review identified and consulted all
the relevant studies rigorously and sufficiently.
Does the review covered all the potential harms
and benefits of the topic?
No – this review mainly focussed on the
benefits of the intervention and only
superficially discussed the potential harms.
Does the review includes only randomised
controlled trials? No – this review considered every kind of study
Are the data presented in a summarised fashion
to provide confidence intervals and estimate of
effect?
No – the data were presented in a descriptive
manner without any analysis.
Are the studies considered here quality
assessed? No selection criteria were set up for this review.
Assessment of the article 3:
Descriptive information about the
study Description
Identification of review
Eteraf-Oskouei, T., & Najafi, M. (2013). Traditional and
modern uses of natural honey in human diseases: a
review. Iranian journal of basic medical sciences, 16(6),
731.
Type of review Non systematic review
What kind of studies have been
considered in the review? All kind of studies have been considered in this review.
Types of outcomes considered in
the review
Both the adverse effect and the benefits have been discussed
in this review.
Whether interventions aimed at
populations or individuals?
The intervention discussed here aimed at the need of human
populations
Evaluation criteria for the review Comments
Does the review identified all relevant studies
rigorously and sufficiently?
Yes – this review have discussed all the relevant
studies rigorously and sufficiently.
Does the review covered all the potential harms
and benefits of the topic?
Yes – this review have investigated both the
benefits and potential harmful effect but the
harmful effect section leaves something to be

6CRITICAL ASSESSMENT OF RESEARCH ARTICLES
desired.
Does the review includes only randomised
controlled trials?
No – this review considered and discussed every
kind of study.
Are the data presented in a summarised fashion
to provide confidence intervals and estimate of
effect?
No – the presented data did not provide
confidence intervals and estimate of effect and
were presented in a descriptive manner.
Are the studies considered here quality
assessed?
No – studies considered in this review were not
quality assessed.
Assessment of article 4:
Descriptive information about the
study Description
Identification of study
Boekema, B. K. H. L., Pool, L., & Ulrich, M. M. W. (2013).
The effect of a honey based gel and silver sulphadiazine on
bacterial infections of in vitro burn wounds. Burns, 39(4),
754-759.
Type of study Randomized controlled trials
What kind of interventions have
been considered and implemented?
Honey based gel was used to treat the burn wound of human
skin. Human skins were obtained by either donation or tissue
bank. Bacterial culture was used to study the bacterial
activity.
Is the intervention aimed at
populations or individuals? The intervention was aimed at the individuals.
Evaluation criteria for the study Comments
Study type Randomized control trial
Are participants of the study well defined in
terms of place, person and time? Yes – subject is well defined in the study.
Is exposure to interventions determined in a
valid, reliable and standard method?
Yes – the method was standard, reliable and
valid
Is exposure to interventions determined in the
same way for both control and intervened
groups?
Yes
Are outcomes determined in a valid, reliable and Yes

7CRITICAL ASSESSMENT OF RESEARCH ARTICLES
standard method?
Are outcomes determined in the same way for
both control and intervened group? Yes
Whether any factors other than intervention
were considered or not?
No – no other factors other than intervention
were considered.
Is the intention of the analysis were to
intervene?
Yes – the intention of the analysis were to
intervene.
Assessment of article 5:
Descriptive information about the
study Description
Identification of study
Noori, A. L., Al Ghamdi, A., Ansari, M. J., Al-Attal, Y., Al-
Mubarak, A., & Salom, K. (2013). Differences in
composition of honey samples and their impact on the
antimicrobial activities against drug multiresistant bacteria
and pathogenic fungi. Archives of medical research, 44(4),
307-316.
Type of study Quasi randomized control study
What kind of interventions have
been considered and implemented?
Five honey samples were collected from different location
and their composition were analysed. After that samples
were used to study the antimicrobial activity by treating
them against microbes such as bacteria and fungi
Is the intervention aimed at
populations or individuals? Interventions were aimed at populations.
Evaluation criteria for the study Comments
Study type Quasi randomized control study
Are participants or parameters of the study well
defined in terms of place, person and time? Yes it is well defined.
Is exposure to interventions determined in a
valid, reliable and standard method? Yes
Is exposure to interventions determined in the
same way for both control and intervened
groups?
Yes

8CRITICAL ASSESSMENT OF RESEARCH ARTICLES
Are outcomes determined in a valid, reliable and
standard method?
Yes – it is determined in valid, reliable and
standard method.
Are outcomes determined in the same way for
both control and intervened group? Yes
Whether any factors other than intervention
were considered or not? Yes – composition of honey were analysed.
Is the intention of the analysis were to
intervene?
Yes – the intention of the analysis were to
intervene.
FORM matrix and evidence body
Grading assessment of the five chosen articles have been described below:
Review or Component
Study Evidence
base
Consistency Clinical
impact
Generaliz-
ability
Applicabilit
y
Jull, Walker
&
Deshpande,
2013
Excellent Excellent Good Excellent Excellent
Maddocks &
Jenkins,
2013
Satisfactory Satisfactory Good Good Excellent
Eteraf-
Oskouei &
Najafi, 2013
Satisfactory Good Good Good Excellent
Boekema &
Ulrich, 2013
Good Good Good Good Excellent
Noori et al.,
2013
Good Good Good Good Excellent

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Discussion
To summarize the above result section, it can be inferred that all the review and
studies were investigating the effect of honey as topical treatment and its efficacy in wound
treatment and antimicrobial activity due to the recent rise drug resistant microbes or
superbug. Jull, Walker & Deshpande (2013) have reviewed the use of honey as a topical
treatment and its use in treating wounds. They have concluded that honey might be effective
in comparison with conventional dressings but there is considerable amount of uncertainty
regarding the acceptability and replicability of this evidence. On the other hand, Maddocks &
Jenkins (2013) have investigated the merit of honey as a solution to the growing problem of
antimicrobial resistance. They have reported in their study that manuka honey have strong
antimicrobial property. On the contrary, Eteraf-Oskouei & Najafi (2013) have investigated
honey in a broad view reported its traditional and modern uses. Similar like previous two
reviews, they have also reported various benefits of honey which can be used to treat various
human diseases. Boekema & Ulrich (2013) have used honey based gel to treat the bacterial
infection of in vitro burn wounds. In their study, they reported that, honey based gel can be
effective alternative for traditional treatments and can be applied in higher frequency.
Additionally, Noori et al., (2013) have investigated the differences in various honey
composition along with their antimicrobial activities towards drug resistant bacteria and
pathogenic fungi. Similar like Boekema & Ulrich (2013), they have also suggested that honey
can be used as a alternative treatment methods against drug resistant microbes. However,
from the assessment and grading described in result section, it can be seen that quality of the
all the paper are not same and Jull, Walker & Deshpande (2013) have published the highest
quality of research as its secured the highest grading regarding the parameters. Papers
published by Boekema & Ulrich (2013) and Noori et al., (2013) are also closely behind in

10CRITICAL ASSESSMENT OF RESEARCH ARTICLES
quality. All of the paper reported the effectiveness of honey as a substitute to antimicrobial
treatment and there is already pre-prepared honey wound dressings is available in the market.
Therefore, honey can be implemented as a treatment to various hospitals and treatment
centres as alternative to reduce the risk of drug resistant microbes. Multiple studies have
reported to the effectiveness of the honey, but very little or no researches have been dedicated
to large scale, robust clinical trials of honey in healthcare. Further research is needed in this
area to reduce gap or limitation whether honey can be used in healthcare as topical treatment.
Conclusion
Therefore, from the above discussion, it can be concluded that honey has the potential
to be used as topical treatment to battle bacterial wound infections. Multiple researches have
been performed in this area and all of them reported that honey has antimicrobial activity.
However, effectiveness of the honey can be varying on the type and location of the harvested
area. Additionally, there is no evidence of large scale clinical trial of honey as an alternative
treatment despite few honey wound dressing available commercially as registered medical
device. Hence, further research and government support is needed to make honey as an
alternative treatment for bacterial wound infections.

11CRITICAL ASSESSMENT OF RESEARCH ARTICLES
References
Boekema, B. K. H. L., Pool, L., & Ulrich, M. M. W. (2013). The effect of a honey based gel
and silver sulphadiazine on bacterial infections of in vitro burn wounds. Burns, 39(4),
754-759.
Eteraf-Oskouei, T., & Najafi, M. (2013). Traditional and modern uses of natural honey in
human diseases: a review. Iranian journal of basic medical sciences, 16(6), 731.
Hillier, S., Grimmer-Somers, K., Merlin, T., Middleton, P., Salisbury, J., Tooher, R., &
Weston, A. (2011). FORM: an Australian method for formulating and grading
recommendations in evidence-based clinical guidelines. BMC medical research
methodology, 11(1), 23.
Jull, A. B., Walker, N., & Deshpande, S. (2013). Honey as a topical treatment for
wounds. Cochrane Database Syst Rev, 2(2).
Maddocks, S. E., & Jenkins, R. E. (2013). Honey: a sweet solution to the growing problem of
antimicrobial resistance?. Future microbiology, 8(11), 1419-1429.
Noori, A. L., Al Ghamdi, A., Ansari, M. J., Al-Attal, Y., Al-Mubarak, A., & Salom, K.
(2013). Differences in composition of honey samples and their impact on the
antimicrobial activities against drug multiresistant bacteria and pathogenic
fungi. Archives of medical research, 44(4), 307-316.
Rychetnik, L., Frommer, M., Hawe, P., & Shiell, A. (2002). Criteria for evaluating evidence
on public health interventions. Journal of Epidemiology & Community Health, 56(2),
119-127.