Rasch analysis of the Antimicrobial Self-Assessment Toolkit for National Health Service (NHS) Trusts (ASAT v17).

OBJECTIVES: The Antimicrobial Self-Assessment Toolkit for National Health Service (NHS) Trusts (ASAT) was developed to evaluate hospital-based antimicrobial stewardship programmes. Iterative validity investigations of the ASAT were used to produce a 91-item ASAT v17 utilizing qualitative methodology. Rasch analysis was used to generate question (item) behaviour estimates and to investigate the validity of ASAT v17. METHODS: In 2012, the partial credit model (PCM) was used to analyse ASAT responses from 33 NHS Trusts within England. WINSTEPS® outputs such as fit statistics and respondent/item maps were examined to determine unidimensionality, item discrimination and item hierarchy. Ordinary least squares regression modelling was used to determine the predictive validity using NHS Trust ability estimates generated from the PCM and corresponding Clostridium difficile rates. RESULTS: Each domain contained items that were misfitting the PCM (with INFIT MNSQ <0.7 or >1.3), except Domain 3. Subsequent iterative item removal had a negligible effect on the fit indices within most ASAT domains. Scale analysis demonstrated that most items were productive for measurement (n = 81). Respondent/item maps showed ceiling effects (n = 3) and floor effects (n = 1) within ASAT domains. Ordinary least squares regression modelling identified that there was limited predictive validity due to the small positive correlation between the predictor and outcome variables for participating hospitals (ρ = 0.146; P = 0.418). CONCLUSIONS: Rasch analysis was an effective measurement technique for evaluating the validity of ASAT v17 by providing evidence that each sub-scale and the overall scale demonstrated unidimensionality (construct validity). Improved item targeting may be required to improve item discrimination within the toolkit.

Reactive oxygen species (ROS) and wound healing: the functional role of ROS and emerging ROS-modulating technologies for augmentation of the healing process.

Reactive oxygen species (ROS) play a pivotal role in the orchestration of the normal wound-healing response. They act as secondary messengers to many immunocytes and non-lymphoid cells, which are involved in the repair process, and appear to be important in coordinating the recruitment of lymphoid cells to the wound site and effective tissue repair. ROS also possess the ability to regulate the formation of blood vessels (angiogenesis) at the wound site and the optimal perfusion of blood into the wound-healing area. ROS act in the host's defence through phagocytes that induce an ROS burst onto the pathogens present in wounds, leading to their destruction, and during this period, excess ROS leakage into the surrounding environment has further bacteriostatic effects. In light of these important roles of ROS in wound healing and the continued quest for therapeutic strategies to treat wounds in general and chronic wounds, such as diabetic foot ulcers, venous and arterial leg ulcers and pressure ulcers in particular, the manipulation of ROS represents a promising avenue for improving wound-healing responses when they are stalled. This article presents a review of the evidence supporting the critical role of ROS in wound healing and infection control at the wound site, and some of the new emerging concepts associated with ROS modulation and its potential in improving wound healing are discussed.

A genomic portrait of the emergence, evolution, and global spread of a methicillin-resistant Staphylococcus aureus pandemic.

The widespread use of antibiotics in association with high-density clinical care has driven the emergence of drug-resistant bacteria that are adapted to thrive in hospitalized patients. Of particular concern are globally disseminated methicillin-resistant Staphylococcus aureus (MRSA) clones that cause outbreaks and epidemics associated with health care. The most rapidly spreading and tenacious health-care-associated clone in Europe currently is EMRSA-15, which was first detected in the UK in the early 1990s and subsequently spread throughout Europe and beyond. Using phylogenomic methods to analyze the genome sequences for 193 S. aureus isolates, we were able to show that the current pandemic population of EMRSA-15 descends from a health-care-associated MRSA epidemic that spread throughout England in the 1980s, which had itself previously emerged from a primarily community-associated methicillin-sensitive population. The emergence of fluoroquinolone resistance in this EMRSA-15 subclone in the English Midlands during the mid-1980s appears to have played a key role in triggering pandemic spread, and occurred shortly after the first clinical trials of this drug. Genome-based coalescence analysis estimated that the population of this subclone over the last 20 yr has grown four times faster than its progenitor. Using comparative genomic analysis we identified the molecular genetic basis of 99.8% of the antimicrobial resistance phenotypes of the isolates, highlighting the potential of pathogen genome sequencing as a diagnostic tool. We document the genetic changes associated with adaptation to the hospital environment and with increasing drug resistance over time, and how MRSA evolution likely has been influenced by country-specific drug use regimens.

Longitudinal trends and cross-sectional analysis of English national hospital antibacterial use over 5 years (2008-13): working towards hospital prescribing quality measures.

OBJECTIVES: There is global concern that antimicrobial resistance is a major threat to healthcare. Antimicrobial use is a primary driver of resistance but little information exists about the variation in antimicrobial use in individual hospitals in England over time or comparative use between hospitals. The objective of this study was to collate, analyse and report issue data from pharmacy records of 158 National Health Service (NHS) acute hospitals. METHODS: This was a cohort study of inpatient antibacterial use in acute hospitals in England analysed over 5 years through a data warehouse from IMS Health, a leading provider of information, services and technology for the healthcare industry. Around 98% of NHS hospitals were included in a country with a population of 50 million residents. RESULTS: There was a dramatic change in the usage of different groups of antibacterials between 2009 and 2013 with a marked reduction in the use of first-generation cephalosporins by 24.7% and second-generation cephalosporins by 41%, but little change in the use of third-generation cephalosporins (+5.7%) and fluoroquinolones (+1.6%). In contrast, use of co-amoxiclav, carbapenems and piperacillin/tazobactam increased by 60.1%, 61.4% and 94.8%, respectively. There was wide variation in the total and relative amounts of antibacterials used between individual hospitals. CONCLUSIONS: Longitudinal analysis of antibacterial use demonstrated remarkable changes in NHS hospitals, probably reflecting governmental and professional guidance to mitigate the risk of Clostridium difficile infection. The wide variation in usage between individual hospitals suggests potential for quality improvement and benchmarking. Quality measures of optimal hospital antimicrobial prescribing need urgent development and validation to support antimicrobial stewardship initiatives.

When antibiotics can be avoided in skin inflammation and bacterial colonization: a review of topical treatments.

PURPOSE OF REVIEW: This review looks at the recent evidence on the safety, toxicity, microbiology and the prevention and management of acute and chronic wound infections with regard to antiseptics and antiseptic wound dressings. It is timely and relevant because of the global concerns of antimicrobial resistance and the need to address the inappropriate use of antimicrobials in the healthcare setting. RECENT FINDINGS: There have been a number of recent Cochrane reviews that have concluded that there is little evidence to delineate clinical outcomes between antiseptics and antiseptic dressings. Published in-vitro evidence offers some new techniques and evaluates some new dressings and antiseptics. There are no economic evaluations of antiseptics and antiseptic dressings. SUMMARY: Better clinical trials on the effectiveness and cost-effectiveness of wound dressings are needed to ensure evidence-based guidance is developed for optimizing the treatment of patients. It is surprising that with the paucity of evidence of clinical effectiveness, healthcare organizations continue to spend considerable resources on poorly evaluated topical wound products.

Association between Clostridium difficile infection and antimicrobial usage in a large group of English hospitals.

AIMS: This study aimed to determine the association between the reduction in the number of Clostridium difficile infection (CDI) cases reported by the English National Health Service (NHS) hospitals and concurrent antimicrobial use. METHODS: A retrospective ecological study for January 2005 to December 2008 was conducted using data from 26 of the 29 NHS trusts (i.e. a trust manages one or more hospitals) located in the North West Strategic Health Authority of England. Antimicrobial use data, for patients of all ages, were provided by IMS Health, and CDI case data for patients aged ≥65 years were provided by the Health Protection Agency. Antimicrobial use was converted into defined daily doses (DDDs). The overall association between antimicrobial use and CDI for the trusts was investigated using multilevel models. RESULTS: Our study shows a positive significant association between the CDI cases and the use of the following antimicrobials: 'third-generation cephalosporins' [11.62 CDI cases per 1000 DDDs; 95% confidence interval (CI), 5.92­17.31]; 'fluoroquinolones' (4.79 CDI cases per 1000 DDDs; 95% CI, 2.83­6.74); and 'second-generation cephalosporins' (4.25 CDI cases per 1000 DDDs; 95% CI, 1.66­6.83). The strength of this association was not significantly different (95% CI) among the antimicrobial groups. CONCLUSIONS: This study shows that the reduction in the number of CDI cases reported by the English NHS hospitals is associated with concurrent reductions in antimicrobial use. This means that the number of CDI cases over time decreased in a similar fashion to the usage of various antimicrobials.

Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence.

OBJECTIVE: To systematically review empirical evidence on the prevalence and nature of medication administration errors (MAEs) in health care settings. DATA SOURCES: Ten electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, Scopus, Applied Social Sciences Index and Abstracts, PsycINFO, Cochrane Reviews and Trials, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, and Health Management Information Consortium) were searched (1985-May 2012). STUDY SELECTION AND DATA EXTRACTION: English-language publications reporting MAE data using the direct observation method were included, providing an error rate could be determined. Reference lists of all included articles were screened for additional studies. DATA SYNTHESIS: In all, 91 unique studies were included. The median error rate (interquartile range) was 19.6% (8.6-28.3%) of total opportunities for error including wrong-time errors and 8.0% (5.1-10.9%) without timing errors, when each dose could be considered only correct or incorrect. The median rate of error when more than 1 error could be counted per dose was 25.6% (20.8-41.7%) and 20.7% (9.7-30.3%), excluding wrong-time errors. A higher median MAE rate was observed for the intravenous route (53.3% excluding timing errors (IQR 26.6-57.9%)) compared to when all administration routes were studied (20.1%; 9.0-24.6%), where each dose could accumulate more than one error. Studies consistently reported wrong time, omission, and wrong dosage among the 3 most common MAE subtypes. Common medication groups associated with MAEs were those affecting nutrition and blood, gastrointestinal system, cardiovascular system, central nervous system, and antiinfectives. Medication administration error rates varied greatly as a product of differing medication error definitions, data collection methods, and settings of included studies. Although MAEs remained a common occurrence in health care settings throughout the time covered by this review, potential targets for intervention to minimize MAEs were identified. CONCLUSIONS: Future research should attend to the wide methodological inconsistencies between studies to gain a greater measure of comparability to help guide any forthcoming interventions.

Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart--Then Focus.

There has been dramatic change in antibiotic use in English hospitals. Data from 2004 and 2009 show that the focus on reducing fluoroquinolone and second- and third-generation cephalosporin use seems to have been heeded in NHS secondary care, and has been associated with a substantial decline in hospital Clostridium difficile rates. However, there has been a substantial increase in use of co-amoxiclav, carbapenems and piperacillin/tazobactam. In primary care, antibiotic prescribing fell markedly from 1995 to 2000, but has since risen steadily to levels seen in the early 1990s. There remains a 2-fold variation in antimicrobial prescribing among English General Practices. In 2010, the NHS Atlas of Variation documented a 3-fold variation in the prescription of quinolones and an 18-fold variation in cephalosporins by Primary Care Trusts across England. There is a clear need to improve antimicrobial prescribing. This paper describes the development of new antimicrobial stewardship programmes for primary care and hospitals by the Department of Health's Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection: Antimicrobial Stewardship in Primary Care Initiative. The secondary care programme promotes the rapid prescription of the right antibiotic at the right dose at the right time, followed by active review for all patients still on antibiotics 48 h after admission. The five options available are to stop, switch to oral, continue and review again, change (if possible to a narrower spectrum) or move to outpatient parenteral antibiotic therapy. A range of audit and outcome tools has been developed, but to maintain optimal antimicrobial usage, monitoring of local and national quantitative and qualitative data on prescribing and consumption is required, linked to the development of key performance indicators in primary, secondary and tertiary care.

Antibiotic stewardship programmes--what's missing?

Inappropriate antibiotic use and antibiotic resistance are now major global issues. Antimicrobial stewardship programmes are increasingly being used to optimize antibiotic prescribing in acute care. The central tenet of these programmes tends to be policy and guidelines aimed at prescribers. However, rules and guidelines alone may not be sufficient to bring about effective and sustainable optimization of practice. Best practice needs to be positively reinforced by an environment that facilitates and supports optimal prescribing choices, i.e. a 'choice architecture' that makes prudent antibiotic prescribing the path of least resistance. To make prudent antibiotic management an integral part of the behaviour of all healthcare professionals and to bring about quality improvement it is necessary to adopt a whole-system approach. To do this it is necessary first to understand the factors that influence antibiotic management and prescribing.

Antimicrobial stewardship: an evidence-based, antimicrobial self-assessment toolkit (ASAT) for acute hospitals.

OBJECTIVES: To describe the methodology in developing an antimicrobial self-assessment toolkit (ASAT). METHODS: The ASAT was developed through a National Pharmacy Reference Group using an evidence-based approach of published information and national reports to identify criteria for inclusion. These were subdivided into domains that addressed: 1) Antimicrobial management within the Trust-structures and lines of responsibility and accountability-high-level notification to the Board. 2) Operational delivery of an antimicrobial strategy-operational standards of good antimicrobial stewardship. 3) Risk assessment for antimicrobial chemotherapy. 4) Clinical governance assurance. 5) Education and training-training needs and delivery of education and training for all who issue, prescribe and administer antimicrobials. 6) Antimicrobial pharmacist-systems in place for ensuring their optimum use. 7) Patients, Carers and the Public-information needs of patients, carers and the public. RESULTS: A web-based toolkit was developed using information from national reports and guidance on antimicrobial stewardship. The toolkit offers a checklist for hospitals to self-assess their organizations' levels of antimicrobial stewardship. CONCLUSIONS: The ASAT offers a web-enabled, version-controlled instrument for the assessment of antimicrobial stewardship in acute hospitals. It may offer a sensitive instrument to assess longitudinal progress on antimicrobial stewardship in an individual institution or act as a benchmark with similar organizations. Further work is ongoing to evaluate and further refine the ASAT.

Respiratory tract infections (RTIs) in primary care: narrative review of C reactive protein (CRP) point-of-care testing (POCT) and antibacterial use in patients who present with symptoms of RTI.

Antimicrobial resistance (AMR) continues to be a global problem and continues to be addressed through national strategies to improve diagnostics, develop new antimicrobials and promote antimicrobial stewardship. Patients who attend general (ambulatory) practice with symptoms of respiratory tract infections (RTIs) are invariably assessed by some sort of clinical decision rule (CDR). However, CDRs rely on a cluster of non-specific clinical observations. A narrative review of the literature was undertaken to ascertain the value of C reactive protein (CRP) point-of-care testing (POCT) to guide antibacterial prescribing in adult patients presenting to general practitioner (GP) practices with symptoms of RTI. Studies that were included were Cochrane reviews, systematic reviews, randomised controlled trials, cluster randomised trials, controlled before and after studies, cohort studies and economic evaluations. An overwhelming number of studies demonstrated that the use of CRP tests in patients presenting with RTI symptoms reduces index antibacterial prescribing. GPs and patients report a good acceptability for a CRP POCT and economic evaluations show cost-effectiveness of CRP POCT over existing RTI management in primary care. POCTs increase diagnostic precision for GPs in the better management of patients with RTI. With the rapid development of artificial intelligence, patients will expect greater precision in diagnosing and managing their illnesses. Adopting systems that markedly reduce antibiotic consumption is a no-brainer for governments that are struggling to address the rise in AMR.

Antibiotic stewardship--more education and regulation not more availability?

Antibiotics are overused across the world by prescription, self-medication or over the counter (OTC) availability. In the UK, the agenda to increase patient choice has stimulated a move towards greater availability of OTC antibiotics. This trend needs to be urgently reviewed and controlled. The Medicines and Healthcare products Regulatory Agency is currently reviewing applications for reclassification of trimethoprim and nitrofurantoin from prescription-only medicines to pharmacy availability or OTC. It is important that anti-infectives do not become more freely available. With the quantity of antibiotic use linked to antibiotic resistance, Society should seek to preserve the use of this irreplaceable resource by education and regulation.

Exploratory randomised controlled clinical study to evaluate the comparative efficacy of two occluding toothpastes - a 5% calcium sodium phosphosilicate toothpaste and an 8% arginine/calcium carbonate toothpaste - for the longer-term relief of dentine hypersensitivity.

OBJECTIVE: To compare the longer-term clinical efficacy of two occlusion-technology toothpastes - a 5% calcium sodium phosphosilicate (CSPS) toothpaste and a commercially available 8% arginine/calcium carbonate toothpaste - in relieving dentine hypersensitivity (DH). Efficacy was also compared with that of a regular fluoride toothpaste control. METHODS: This was an exploratory, randomised, examiner-blind, parallel-group, 11-week, controlled study in healthy adults with self-reported and clinically diagnosed DH. After an acclimatisation period, subjects were randomised to one of three study treatments with which they brushed their teeth twice daily. Sensitivity was assessed at baseline and after 1, 2, 4, 6 and 11 weeks treatment in response to evaporative (air) and tactile stimuli (measured by the Schiff Sensitivity Scale/visual analogue scale and tactile threshold, respectively). RESULTS: A total of 135 subjects were randomised to treatment. The two occlusion-technology toothpastes performed similarly over the 11-week treatment period. All study treatments showed statistically significant reductions from baseline in DH at all timepoints for all measures (p<0.05). Statistically significant and clinically relevant sensitivity relief was observed for both occluding formulations compared with the regular fluoride toothpaste: for evaporative (air) sensitivity within 1 week and for tactile sensitivity at Week 11. No significant differences were detected between the two occluding formulations at any timepoint, for any endpoint. Study treatments were generally well tolerated. CONCLUSIONS: In this exploratory study, a 5% CSPS occluding toothpaste was effective in relieving DH compared with a regular fluoride toothpaste; an 8% arginine/calcium carbonate anti-sensitivity toothpaste provided similar benefits. Improvements in DH continued throughout the 11-week study. CLINICAL SIGNIFICANCE: Dentine hypersensitivity (DH) is a common and painful condition. Twice-daily use of a 5% calcium sodium phosphosilicate toothpaste reduces DH within 1-2 weeks of initiating use. Ongoing, twice daily use of the sensitivity toothpastes evaluated in this study was associated with continued, clinically significant improvements in DH.

Hot topics in reactive oxygen therapy: Antimicrobial and immunological mechanisms, safety and clinical applications.

Reactive oxygen species (ROS), when combined with various delivery mechanisms, has the potential to become a powerful novel therapeutic agent against difficult-to-treat infections, especially those involving biofilm. It is important in the context of the global antibiotic resistance crisis. ROS is rapidly active in vitro against all Gram-positive and Gram-negative bacteria tested. ROS also has antifungal and antiviral properties. ROS prevents the formation of biofilms caused by a range of bacterial species in wounds and respiratory epithelium. ROS has been successfully used in infection prevention, eradication of multiresistant organisms, prevention of surgical site infection, and intravascular line care. This antimicrobial mechanism has great potential for the control of bioburden and biofilm at many sites, thus providing an alternative to systemic antibiotics on epithelial/mucosal surfaces, for wound and cavity infection, chronic respiratory infections and possibly recurrent urinary infections as well as local delivery to deeper structures and prosthetic devices. Its simplicity and stability lend itself to use in developing economies as well.

Reactive oxygen: A novel antimicrobial mechanism for targeting biofilm-associated infection.

Reactive oxygen species (ROS) is a novel therapeutic strategy for topical or local application to wounds, mucosa or internal structures where there may be heavy bacterial bioburden with biofilm and chronic inflammation. Bacterial biofilms are a significant problem in clinical settings owing to their increased tolerance towards conventionally prescribed antibiotics and their propensity for selection of further antibacterial resistance. There is therefore a pressing need for the development of alternative therapeutic strategies that can improve antibiotic efficacy towards biofilms. ROS has been successful in treating chronic wounds and in clearing multidrug-resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA), and carbapenemase-producing isolates from wounds and vascular line sites. There is significant antifungal activity of ROS against planktonic and biofilm forms. Nebulised ROS has been evaluated in limited subjects to assess reductions in bioburden in chronically colonised respiratory tracts. The antibiofilm activity of ROS could have great implications for the treatment of a variety of persistent respiratory conditions. Use of ROS on internal prosthetic devices shows promise. A variety of novel delivery mechanisms are being developed to apply ROS activity to different anatomical sites.

Medication management in English National Health Service hospitals.

PURPOSE: The methods currently used by English National Health Service (NHS) hospitals to manage the use of medicines were studied. METHODS: A questionnaire was mailed to directors of pharmacy at all English NHS hospitals in May 2001. RESULTS: The response rate was 57% (157/ 275). Sixty-six percent of the responding hospitals provided general acute care services, and 34% provided mental health services. About 1 responder in 5 (19%) was a specialty hospital functioning either as a freestanding institution or alongside other hospitals. The average total expenditure by the hospital trusts was pound 94 million (dollar 175 million), of which drugs accounted for pound 3.5 million (dollar 6.5 million). Many hospitals either had formularies or were constructing them (86%), and most hospitals used a process to manage the introduction of new medicines. About three fourths of the hospitals had < or = 20 pharmacist full-time equivalents. The implementation of national guidelines was variable, although some of this variation may have been due to differences in service provision. Few hospitals were actively monitoring compliance with guidelines (31%), but audits of current care were common (72%). CONCLUSION: A survey of English NHS hospitals provided information on pharmacy staffing, drug expenditures, and measures taken to ensure rational medication use.

Prescribing incentive schemes : a useful approach?

INTRODUCTION: From 2000 to 2004, primary care organisations (PCOs) in England were legally required to operate a prescribing incentive scheme for their general practices. A statutory framework specified the types of target, maximum rewards and use of 'good cause for failure' provisions that schemes should include. Our objective was to explore whether schemes might be a useful approach to encourage 'good quality' prescribing. METHODS: We requested copies of the original schemes from all PCOs in England in 2001 and 2002. Data were extracted on the rewards offered, types of budgetary targets set and additional conditions specified. RESULTS: Many schemes had not been finalised, some PCOs had no scheme, and one scheme operated without rewards. Although schemes covered similar therapeutic areas, they varied considerably in their length, complexity, reward levels and reward structure. Over half the schemes contained no 'good cause for failure' provision. DISCUSSION/CONCLUSION: PCOs are offering diverse incentives to general practices and some have interpreted the statutory framework imaginatively. Better use of the 'good cause for failure' provision may help to overcome inflationary pressures on prescribing, but further research is needed to clarify the role of financial incentives in influencing prescribing.

Perspectives of clinical microbiologists on antimicrobial stewardship programmes within NHS trusts in England.

BACKGROUND: The Antimicrobial Self-Assessment Toolkit for NHS Trusts (ASAT) was developed in England by a National Pharmacist Reference Group of an Advisory Non-Departmental Public Body on Antimicrobial Resistance and Healthcare Associated Infections (ARHAI), in conjunction with the Department of Health. It is intended to identify and evaluate interventions for the promotion and implementation hospital-based antimicrobial stewardship programmes (ASPs). ASAT v16 was produced by iterative validity testing with end-users utilising a sequential exploratory strategy. It was highlighted that there was a need for the inclusion of the domain which targeted the role of clinical microbiologists due to their substantial roles in hospital-based ASP development and implementation. METHODS: This study aimed to investigate the content validity of ASAT v16 and a proposed draft domain for clinical microbiologists and hence produce ASAT v17. From June to September 2011, semi-structured interviews were conducted with ten consultant clinical microbiologists from secondary and tertiary care National Health Service (NHS) Trusts within England. Interviews were conducted until no novel themes were identified i.e., data saturation was achieved. Each interview was digitally recorded and transcribed verbatim and then analysed using a thematic framework that facilitated the identification of emergent themes and sub-themes. RESULTS: Nine emergent themes were identified which included common enablers and challenges associated with the implementation of effective and sustainable hospital-based ASPs. Key themes included formal governmental mandates, IT infrastructure and also prescribers' knowledge base of antimicrobial chemotherapy and infectious diseases. Most respondents agreed with the content of ASATv16 and the proposed draft section however they suggested that minor modifications were required to improve question sensitivity and hence reduce measurement error. CONCLUSIONS: Although, the ASAT been through multiple iterations and content validity testing, further modifications were required to produce the next iteration, ASAT v17. Question merging and other minor modifications were conducted as indicated by study findings. This study reinforces the need for stakeholder engagement during the development and implementation of tools that evaluate hospital-based implementation strategies.

The antimicrobial activity of prototype modified honeys that generate reactive oxygen species (ROS) hydrogen peroxide.

BACKGROUND: Antimicrobial resistance continues to be a global issue in healthcare organisations. Honey has long been shown to possess wound healing and antimicrobial properties that are dependent on a number of physical and chemical properties of the honey. We tested the antimicrobial activity of a medicinal honey, Surgihoney® (SH) and two prototype modified honeys made by Apis mellifera (honeybee) against Staphylococcus aureus (NCIMB 9518). We also examined the modified honey prototypes for the ability to generate reactive oxygen species (ROS) by changing the level of production of hydrogen peroxide from the samples. METHODS: Surgihoney® (SH) was compared with two modified honeys, Prototype 1 (PT1) and Prototype 2 (PT2) using a bioassay method against a standard strain of Staphylococcus aureus. Further work studied the rate of generation of ROS hydrogen peroxide from these preparations. RESULTS: Surgihoney® antimicrobial activity was shown to be largely due to ROS hydrogen peroxide production. By modification of Surgihoney®, two more potent honey prototypes were shown to generate between a two- and three-fold greater antibacterial activity and up to ten times greater ROS peroxide activity. CONCLUSIONS: Surgihoney® is a clinically available wound antiseptic dressing that shows good antimicrobial activity. Two further honey prototypes have been shown to have antimicrobial activity that is possible to be enhanced due to demonstrated increases in ROS peroxide activity.