實證醫學 嘉義基督教醫院 外科部　黃國倉醫師 2012.04.20

臨床問題敘述(Problem description)： 近日一項研究發現，紐西蘭、澳洲出產的麥蘆卡蜂蜜或可幫助清除慢性傷口感染，甚至可預防傷口感染，而古代傳統藥方亦曾有使用蜂蜜治療局部傷口的作法，不過醫界還不太了解蜂蜜中的抗菌物質。隨著抗生素抗藥性問題越來越嚴重，蜂蜜真可以提供細菌感染患者另一種治療選擇嗎？

實證醫學五步驟 步驟一： 形成一個可回答的臨床問題 步驟二： 搜尋最佳證據 步驟三： 嚴格評讀證據 步驟四： 應用證據於病患身上 步驟五： 評估執行效果及效用 3

近日一項研究發現，紐西蘭、澳洲出產的麥蘆卡蜂蜜或可幫助清除慢性傷口感染，甚至可預防傷口感染，而古代傳統藥方亦曾有使用蜂蜜治療局部傷口的作法，不過醫界還不太了解蜂蜜中的抗菌物質。隨著抗生素抗藥性問題越來越嚴重，蜂蜜真可以提供細菌感染患者另一種治療選擇嗎？ PICO ? Patient/Problem：Chronic ulcer, infection Intervention：Honey Comparison：Antibiotic therapy Outcome：Infection control P: Infection or/and poor healing wound I: Medical honey C: Without medical honey O: Infection control Patient/Problem：Ulcers wound Intervention：Manuka Honey wound care Comparison：Usual or hydrogel wound care Outcome：Outcome treatment Patient/Problem：Patient with an acute or chronic wound Intervention：Treatment with honey Comparison：Traditional treatment Outcome：1. Time to complete wound healing 2. Proportion of participants with completely healed wounds

實證醫學五步驟 步驟一： 形成一個可回答的臨床問題 步驟二： 搜尋最佳證據 步驟三： 嚴格評讀證據 步驟四： 應用證據於病患身上 步驟五： 評估執行效果及效用 5

臨床問題的類別 Therapy Harm / Etiology Diagnosis (tests) Prognosis select treatments that do more good than harm, worth the efforts and costs of using them Harm / Etiology identify causes of disease (including iatrogenic forms) Diagnosis (tests) select and interpret diagnostic tests Prognosis estimate the patient's likely clinical course over time and anticipate likely complications of disease

依問題性質選最佳的研究方法 不同研究設計的證據等級不同 依問題性質選最佳的研究方法 Frequency - Prevalence (case control), Incidence (cohort) Etiology / Harm - cohort Diagnosis – case control Prognosis - cohort Treatment / Intervention - RCT 7

關鍵字(Key words): Honey, bacterial infection, wound 資料庫搜尋敘述(Literature search):（建議至少搜尋PubMed, Medline, Cochrane, NGC） Search PubMed: Search Add to builder Query Items found #1 Add Search honey 5518 #2 Search bacterial infection 747007 #3 Search wound 749877 #4 Search (#2) OR #3 1466108 #5 Search (#4) AND #1 534 #6 Search (#4) AND #1 Limits: Clinical Trial, Meta-Analysis, Randomized Controlled Trial 46 #7 Search (#4) AND #1 Limits: Meta-Analysis 2

參考文獻摘要與等級：(Level 1A:systemic review of RCT；Level 1B:single RCT; Level 2A:systemic review of cohort study；level 2B:cohort study or poor RCTs；Level 3:case control；Level 4:case series；Level 5:expert opinion) [1]: Level 1A:systemic review of RCT Jull AB, Rodgers A, Walker N. Honey as a topical treatment for wounds. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD005083. AUTHORS' CONCLUSIONS: Honey may improve healing times in mild to moderate superficial and partial thickness burns compared with some conventional dressings. Honey dressings as an adjuvant to compression do not significantly increase leg ulcer healing at 12 weeks. There is insufficient evidence to guide clinical practice in other areas.

參考文獻摘要與等級：(Level 1A:systemic review of RCT；Level 1B:single RCT; Level 2A:systemic review of cohort study；level 2B:cohort study or poor RCTs；Level 3:case control；Level 4:case series；Level 5:expert opinion) [2]:Level 1B:single RCT Lund-Nielsen B, Adamsen L, Kolmos HJ, Rørth M, Tolver A, Gottrup F. The effect of honey-coated bandages compared with silver-coated bandages on treatment of malignant wounds-a randomized study. Wound Repair Regen. 2011 Nov;19(6):664-70. Patients were randomly selected to enter either group A (honey-coated bandages) or group B (silver-coated bandages). The use of honey-coated and silver-coated bandages improved the outcome of MWs(Malignant wounds). No differences were found between the two regimens.

參考文獻摘要與等級：(Level 1A:systemic review of RCT；Level 1B:single RCT; Level 2A:systemic review of cohort study；level 2B:cohort study or poor RCTs；Level 3:case control；Level 4:case series；Level 5:expert opinion) [3]:Level 1B:single RCT Shoma A, Eldars W, Noman N, Saad M, Elzahaf E, Abdalla M, Eldin DS, Zayed D, Shalaby A, Malek HA. Pentoxifylline and local honey for radiation-induced burn following breast conservative surgery. Curr Clin Pharmacol. 2010 Nov;5(4):251-6. Group A received standard burn treatment (control group). Group B received additionally 400 mg PTX (pentoxifylline) twice daily. Group C received the same treatment as Group B with adding topical purified honey ointment. CONCLUSION: Combination of PTX and honey is an ideal measure for treatment of radiation-induced burn following breast conservative surgery.

參考文獻摘要與等級：(Level 1A:systemic review of RCT；Level 1B:single RCT; Level 2A:systemic review of cohort study；level 2B:cohort study or poor RCTs；Level 3:case control；Level 4:case series；Level 5:expert opinion) [4]:Level 1B:single RCT Malik KI, Malik MA, Aslam A. Honey compared with silver sulphadiazine in the treatment of superficial partial-thickness burns. Int Wound J. 2010 Oct;7(5):413-7. Each patient had one burn site treated with honey and one treated with topical SSD (silver sulphadiazine ), randomly. The results clearly showed greater efficacy of honey over SSD cream for treating superficial and partial-thickness burns.

參考文獻摘要與等級：(Level 1A:systemic review of RCT；Level 1B:single RCT; Level 2A:systemic review of cohort study；level 2B:cohort study or poor RCTs；Level 3:case control；Level 4:case series；Level 5:expert opinion) [5]:Level 1B:single RCT Robson V, Dodd S, Thomas S. Standardized antibacterial honey (Medihoney) with standard therapy in wound care: randomized clinical trial. J Adv Nurs. 2009 Mar;65 (3):565-75. METHOD: A sample of 105 patients were involved in a single centre, open-label randomized controlled trial in which patients received either a conventional wound dressing or honey. These results support the proposition that there are clinical benefits from using honey in wound care, but further research is needed.

參考文獻摘要與等級：(Level 1A:systemic review of RCT；Level 1B:single RCT; Level 2A:systemic review of cohort study；level 2B:cohort study or poor RCTs；Level 3:case control；Level 4:case series；Level 5:expert opinion) [6]:Level 1B:single RCT Gethin G, Cowman S. Manuka honey vs. hydrogel--a prospective, open label, multicentre, randomized controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. J Clin Nurs. 2009 Feb;18(3):466-74. OBJECTIVE: Comparison of desloughing efficacy after four weeks and healing outcomes after 12 weeks in sloughy venous leg ulcers treated with Manuka honey (Woundcare 18+) vs. standard hydrogel therapy (IntraSite Gel). CONCLUSION: The WoundCare 18+ group had increased incidence of healing, effective desloughing and a lower incidence of infection than the control. Manuka honey has therapeutic value and further research is required to examine its use in other wound aetiologies.

參考文獻摘要與等級：(Level 1A:systemic review of RCT；Level 1B:single RCT; Level 2A:systemic review of cohort study；level 2B:cohort study or poor RCTs；Level 3:case control；Level 4:case series；Level 5:expert opinion) Honey in the treatment of burns: a systematic review and meta-analysis of its efficacy. Wijesinghe M, Weatherall M, Perrin K, Beasley R. N Z Med J. 2009 May 22;122(1295):47-60. Review. CONCLUSION: Available evidence indicates markedly greater efficacy of honey compared with alternative dressing treatments for superficial or partial thickness burns, although the limitations of the studies included in the meta-analysis restrict the clinical application of these findings. Further studies are urgently required to determine the role of honey in the management of superficial or partial thickness burns.

國內對蜂蜜敷料相對保守些，有待更多臨床證據來檢驗其療效。針對一般民眾應警告切勿胡亂將任何蜂蜜用於治療傷口之用，因為醫療級蜂蜜與一般食用蜂蜜完全不同，需經醫師同意後使用。

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