Research Article| Volume 98, ISSUE 2, P141-148, February 2018

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Randomized controlled trial of honey versus mupirocin to decolonize patients with nasal colonization of meticillin-resistant Staphylococcus aureus

Published:October 26, 2017DOI:



      Mupirocin is used specifically for the eradication of nasal meticillin-resistant Staphylococcus aureus (MRSA), but increasing mupirocin resistance restricts its repeated use. The antibacterial effects of manuka honey have been established in vitro; antibacterial activity of other honeys has also been reported.


      To describe the learning experience from a randomized controlled trial (RCT) comparing the efficacy of medical-grade honey (MGH) with mupirocin 2% for the eradication of nasal MRSA.


      Patients colonized in the nose with MRSA and age ≥18 years were recruited. Participants received either one or two courses of MGH or mupirocin 2%, three times per day for five consecutive days.


      The proportion of patients who were decolonized after one or two courses of treatment was not significantly different between MGH [18/42; 42.8%; 95% confidence interval (CI): 27.7–59.0] and mupirocin 2% (25/44; 56.8%; 95% CI: 41.0–71.7). Non-nasal MRSA colonization was significantly associated with persistent nasal colonization (odds ratio: 5.186; 95% CI: 1.736–5.489; P = 0.003). The rate of new acquisition of mupirocin resistance was 9.75%.


      Although not significant, a decolonization rate of 42.8% for MGH was impressive. Our findings suggest that this strategy, which has the potential to combat antimicrobial resistance, should be assessed in similar but larger studies.


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        • Marzec N.S.
        • Bessesen M.T.
        Risk and outcomes of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia among patients admitted with and without MRSA nares colonization.
        Am J Infect Control. 2016; 44: 405-408
        • Leigh D.A.
        • Joy G.
        Treatment of familial staphylococcal infection – comparison of mupirocin nasal ointment and chlorhexidine/neomycin (Naseptin) cream in eradication of nasal carriage.
        J Antimicrob Chemother. 1993; 31: 909-917
        • Walsh T.J.
        • Standiford H.C.
        • Reboli A.C.
        • John J.F.
        • Mulligan M.E.
        • Ribner B.S.
        • et al.
        Randomized double-blinded trial of rifampin with either novobiocin or trimethoprim-sulfamethoxazole against methicillin-resistant Staphylococcus aureus colonization: prevention of antimicrobial resistance and effect of host factors on outcome.
        Antimicrob Agents Chemother. 1993; 37: 1334-1342
        • Harbarth S.
        • Dharan S.
        • Liassine N.
        • Herrault P.
        • Auckenthaler R.
        • Pittet D.
        Randomized, placebo-controlled, double-blind trial to evaluate the efficacy of mupirocin for eradicating carriage of methicillin-resistant Staphylococcus aureus.
        Antimicrob Agents Chemother. 1999; 43: 1412-1416
        • Coia J.E.
        • Duckworth G.J.
        • Edwards D.I.
        • Farrington M.
        • Fry C.
        • Humphreys H.
        • et al.
        Guidelines for the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities.
        J Hosp Infect. 2006; 63: S1-S44
        • National Clinical Effectiveness Committee
        Prevention and control methicillin-resistant Staphylococcus aureus (MRSA).
        National Clinical Guideline No. 2, 2013
        • Calfee D.P.
        • Salgado C.D.
        • Milstone A.M.
        • Harris A.D.
        • Kuhar D.T.
        • Moody J.
        • et al.
        Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute care hospitals: 2014 update.
        Infect Control Hosp Epidemiol. 2014; 35: 772-796
        • Lee A.S.
        • Macedo-Vinas M.
        • François P.
        • Renzi G.
        • Schrenzel J.
        • Vernaz N.
        • et al.
        Impact of combined low-level mupirocin and genotypic chlorhexidine resistance on persistent methicillin-resistant Staphylococcus aureus carriage after decolonization therapy: a case–control study.
        Clin Infect Dis. 2011; 52: 1422-1430
        • Poovelikunnel T.
        • Gethin G.
        • Humphreys H.
        Mupirocin resistance: clinical implications and potential alternatives for the eradication of MRSA.
        J Antimicrob Chemother. 2015; 70: 2681-2692
        • Sherlock O.
        • Dolan A.
        • Athman R.
        • Power A.
        • Gethin G.
        • Cowman S.
        • et al.
        Comparison of the antimicrobial activity of Ulmo honey from Chile and Manuka honey against methicillin-resistant Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa.
        BMC Compl Alter Med. 2010; 10: 47
        • Maddocks S.E.
        • Jenkins R.E.
        • Rowlands R.S.
        • Purdy K.J.
        • Cooper R.A.
        Manuka honey inhibits adhesion and invasion of medically important wound bacteria in vitro.
        Future Microbiol. 2013; 8: 1523-1536
        • Maeda Y.
        • Loughrey A.
        • Earle J.A.
        • Millar B.C.
        • Rao J.R.
        • Kearns A.
        • et al.
        Antibacterial activity of honey against community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA).
        Compl Ther Clin Pract. 2008; 14: 77-82
        • Gethin G.
        • Cowman S.
        Bacteriological changes in sloughy venous leg ulcers treated with manuka honey or hydrogel: an RCT.
        J Wound Care. 2008; 17: 241
        • Natarajan S.
        • Williamson D.
        • Grey J.
        • Harding K.G.
        • Cooper R.A.
        Healing of an MRSA-colonized, hydroxyurea-induced leg ulcer with honey.
        J Dermat Treat. 2001; 12: 33-36
        • Kamaratos A.V.
        • Tzirogiannis K.N.
        • Iraklianou S.A.
        • Panoutsopoulos G.I.
        • Kanellos I.E.
        • Melidonis A.I.
        Manuka honey-impregnated dressings in the treatment of neuropathic diabetic foot ulcers.
        Int Wound J. 2014; 11: 259-263
        • Siavash M.
        • Shokri S.
        • Haghighi S.
        • Shahtalebi M.A.
        • Farajzadehgan Z.
        The efficacy of topical royal jelly on healing of diabetic foot ulcers: a double-blind placebo-controlled clinical trial.
        Int Wound J. 2015; 12: 137-142
        • Blaser G.
        • Santos K.
        • Bode U.
        • Vetter H.
        • Simon A.
        Effect of medical honey on wounds colonised or infected with MRSA.
        J Wound Care. 2007; 16: 325-328
        • Anthimidou E.
        • Mossialos D.
        Antibacterial activity of Greek and Cypriot honeys against Staphylococcus aureus and Pseudomonas aeruginosa in comparison to manuka honey.
        J Medicinal Food. 2013; 16: 42-47
        • Nishio E.K.
        • Ribeiro J.M.
        • Oliveira A.G.
        • Andrade C.G.
        • Proni E.A.
        • Kobayashi R.K.
        • et al.
        Antibacterial synergic effect of honey from two stingless bees: Scaptotrigona bipunctata Lepeletier, 1836, and S. postica Latreille, 1807.
        Scientific Reports. 2016; 6: 21641
        • Kus P.M.
        • Szweda P.
        • Jerkovic I.
        • Tuberoso C.I.
        Activity of Polish unifloral honeys against pathogenic bacteria and its correlation with colour, phenolic content, antioxidant capacity and other parameters.
        Lett Appl Microbiol. 2016; 62: 269-276
        • Henriques A.F.
        • Jenkins R.E.
        • Burton N.F.
        • Cooper R.A.
        The intracellular effects of manuka honey on Staphylococcus aureus.
        Eur J Clin Microbiol Infect Dis. 2010; 29: 45-50
        • Siegel J.D.
        • Rhinehart E.
        • Jackson M.
        • Chiarello L.
        2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings.
        Am J Infect Cont. 2007; 35: S65-S164
        • Cherkaoui A.
        • Renzi G.
        • Francois P.
        • Schrenzel J.
        Comparison of four chromogenic media for culture-based screening of meticillin-resistant Staphylococcus aureus.
        J Med Microbiol. 2007; 56: 500-503
        • EUCAST
        European Committee on Antimicrobial Susceptibility Testing clinical breakpoints – bacteria (v3.1) February 2013.
        EUCAST, Växjö, Sweden2013
        • Landelle C.
        • von Dach E.
        • Haustein T.
        • Agostinho A.
        • Renzi G.
        • Renzoni A.
        • et al.
        Randomized, placebo-controlled, double-blind clinical trial to evaluate the efficacy of polyhexanide for topical decolonization of MRSA carriers.
        J Antimicrob Chemother. 2016; 71: 531-538
        • Wertheim H.F.
        • Vos M.C.
        • Ott A.
        • Voss A.
        • Kluytmans J.A.
        • Vandenbroucke-Grauls C.M.
        • et al.
        Mupirocin prophylaxis against nosocomial Staphylococcus aureus infections in nonsurgical patients: a randomized study.
        Ann Intern Med. 2004; 140: 419-425
        • Sulaiman I.
        • Cushen B.
        • Greene G.
        • Seheult J.
        • Seow D.
        • Rawat F.
        • et al.
        Objective Assessment of adherence to inhalers by patients with chronic obstructive pulmonary disease.
        Am J Resp Crit Care Med. 2017; 195: 1333-1343
        • Abegaz T.M.
        • Shehab A.
        • Gebreyohannes E.A.
        • Bhagavathula A.S.
        • Elnour A.A.
        Nonadherence to antihypertensive drugs: a systematic review and meta-analysis.
        Medicine. 2017; 96e5641
        • Cohen C.C.
        • Cohen B.
        • Shang J.
        Effectiveness of contact precautions against multidrug-resistant organism transmission in acute care: a systematic review of the literature.
        J Hosp Infect. 2015; 90: 275-284
        • McKinnell J.A.
        • Eells S.J.
        • Clark E.
        • Rand D.D.
        • Kiet G.T.
        • Macias-Gil R.
        • et al.
        Discontinuation of contact precautions with the introduction of universal daily chlorhexidine bathing.
        Epidemiol Infect. 2017; 145: 2575-2581
        • Sai N.
        • Laurent C.
        • Strale H.
        • Denis O.
        • Byl B.
        Efficacy of the decolonization of methicillin-resistant Staphylococcus aureus carriers in clinical practice.
        Antimicrob Resist Infect Cont. 2015; 4: 56
        • Deeny S.R.
        • Worby C.J.
        • Tosas Auguet O.
        • Cooper B.S.
        • Edgeworth J.
        • Cookson B.
        • et al.
        Impact of mupirocin resistance on the transmission and control of healthcare-associated MRSA.
        J Antimicrob Chemother. 2015; 70: 3366-3378
        • Blair S.E.
        • Cokcetin N.N.
        • Harry E.J.
        • Carter D.A.
        The unusual antibacterial activity of medical-grade Leptospermum honey: antibacterial spectrum, resistance and transcriptome analysis.
        Eur J Clin Microbiol Infect Dis. 2009; 28: 1199-1208
        • Cooper R.A.
        • Jenkins L.
        • Henriques A.F.
        • Duggan R.S.
        • Burton N.F.
        Absence of bacterial resistance to medical-grade manuka honey.
        Eur J Clin Microbiol Infect Dis. 2010; 29: 1237-1241
        • Jull A.B.
        • Walker N.
        • Deshpande S.
        Honey as a topical treatment for wounds.
        Cochrane Database Syst Rev. 2013; CD005083