1. Evidence-based Practice Parts I, II & III Treating & Preventing MRSA Colonization & Infection with Manuka Herbals (Special focus on Corrections) By Lori Kelsey RN DOM University of St. Francis

2. Part I: Background

3. MRSA
Poor quality evidence for health maintenance & disease prevention against MRSA. National Guideline Clearinghouse decolonizing protocol for MRSA includes mupirocin, Chlorhexidine (Hiblclens®), and diluted bleach baths. There is only class C-III evidence- lowest ranked evidence- supporting the protocol’s efficacy.

4. Morbidity to Mortality
MRSA
Morbidity to Mortality
Asymptomatic carrier/colonized states
skin, respiratory, GU/GI, bone & CNS infections
fulminating wounds & sepsis

5. Are Manuka Herbals a means to these ends?
MRSA vs. MANUKA
A means of reducing the bacterial bio-burden of MRSA, other than by the use of topical and systemic antibiotics, is urgently required
(Harding & Cooper, 2001).
Are Manuka Herbals a means to these ends?

6. Manuka- Leptosperma scoparium
A tree whose herbals inhibit strains of MRSA
Raw plant components
Volatile oil (essential oil/ EO)
Manuka honey (Medihoney®)

7. Manuka- Leptosperma scoparium
Therapeutic Principles
Unique-Manuka-Factor (UMF): derived from raw plant components (Cooper, 2008 and Molan, 1992).
Cyclic triketones: leptospermone, isoleptosperone & flavesone (20-30%) in the EO are potent antimicrobial. Non toxic compared to other ketones.
Non-peroxide type honey: unlikely to be inactivated by catalase, an enzyme in human tissue or plasma that destroys hydrogen peroxide (an antimicrobial made by macrophages).
Potent antimicrobials: manuka honey can be equivalent to 10% phenol (Cooper, 2008). Manuka EO inhibited a strain of MRSA at 0.2% or 200 ppm - very diluted (Cooke & Cooke (2001). (

8. Manuka- Leptosperma scoparium
Medihoney® by DermaScience Standard of Care in some physical therapy departments for the treatment of wounds that are colonized or infected with MRSA. Integrative Medicine

9. Manuka- Leptosperma scoparium
Different types of Manuka-based products
need to be developed and tested
(e.g. treatment gel & soap)
An EO blend was found to inhibit many MRSA strains in-vitro.
Then formulated into proprietary sundries called Mercy soap
& Mercy treatment gel. They contain tea tree EO, which is 20x
less potent than Manuka EO against gram+ bacteria like MRSA
(Cawthorn). These sundries have not been tested in-vivo for
health maintenance & disease prevention against MRSA
colonization.

10. Part II: The PICOT Question & Evidence

11. The PICOT Question Population: Will at risk individuals
Intervention: who swabbed their nares with Manuka essential oil-based treatment gel
Comparison: compared to the at risk individuals with no intervention
Outcome: have less incidence & prevalence of MRSA colonization in the nares
Time: when administered once per day for 1 month?

12. Quantitative (level 2) Evidence
No variation in outcomes among quantitative studies (n=18) that tested Manuka Herbals
Type: in-vivo & in-vitro
Variations: investigators, conditions, strains of MDROs (e.g. MRSA, VRE etc.), Manuka EO & honey, other types of honey.
Replicated: 1 in-vivo study

13. Quantitative Evidence (continued)
All interventions were highly effective in:
Eradicating MRSA from colonized or infected wounds.
Healing of recalcitrant wounds that were colonized with MRSA.
inhibition of MRSA strains in vitro.
No formed resistance by MRSA strains.

14. Quantitative Evidence (continued)
The evidence for Manuka-based herbals is sufficient, but not complete for EBP.
Need meta-analysis on Medihoney®
level 1 evidence for an interventions efficacy.
Need broad-spectrum analysis on EO
epidemic MRSA15 (spreads most rapidly) vs. Oxford S. aureaus (antibiotic sensitive) vs. any untypable MRSA strains; CA-MRSA vs. HA-MRSA?

15. Quantitative Studies Blinded Random-Controlled Trail (replicated)
Bacteriological Changes in Sloughing Venous Leg Ulcers with Manuka Honey or Hydrogel (Gethin & Cowman, 2008).
Laboratory Analysis:
An Investigation Into The Antimicrobial Properties Of Manuka And Kanuka Oil (Cooke & Cooke, 2001).
The Effect Of Essential Oils On Methicillin-Resistant Staphylococcus Aureus Using A Dressing Model (Edwards-Jones, Buck, Shawcross, Dawson, Dunn, 2004).
Descriptive, Correlation, Predictive (seminal):
Wide Variation in Adoption of Screening and Infection Control Interventions for Multidrug Resistant Organisms (Pogorzelska, Stone & Larson, 2012)

16. Qualitative (level 6) Evidence
3 studies measured patient and/or provider attitudes towards and willingness to use Integrative Medicine.
2 used valid & reliable measurement instruments: positive attitudes & willingness
1 study had selection bias: desire for integrated approaches to healthcare.

17. Qualitative Studies Phenomenological & Instrument Validation:
Themes of Holism, Empowerment, Access, and Legitimacy Define Complementary, Alternative, and Integrative Medicine in Relation to Conventional Biomedicine (Barrett et al, 2003).
Comparative survey of Complementary and Alternative Medicine (CAM) attitudes, use, and information-seeking behavior among medical students, residents & faculty (Lie, D., & Boker, 2006).
The Development and Validation of IMAQ: Integrative Medicine Attitude Questionnaire (Schneider, Meek & Bell, 2003).

18. Case Study (level 6) Evidence
Contradictory to, or supportive of
the efficacy of Manuka herbals?
4 case studies: Manuka honey facilitated wound healing, eliminated infection, but did not reduce MDRO colonization.
1 case study: Manuka honey healed a chronic wound that was refractory to standard therapies due to an immune-inhibiting drug (without discontinuing the drug).
Comparing clinical outcomes: level 6 evidence is inferior to level 2 evidence. No conflicting level 2 evidence.

19. Case Study (continued)
Treatment of an Infected Venous Leg Ulcer with Honey Dressings (Alcaraz & Kelly, 2002).
Healing of an MRSA-colonized, Hydroxyurea-induced Leg Ulcer with Honey (Natarajan, Williamson, Grey, Harding & Cooper, 2001).
Manuka honey used to Heal a Recalcitrant Surgical Wound (Cooper, Molan, Krishnamoorthy & Harding, 2001)

20. Expert & Literature Review (level 7) Evidence
Burdens of Concern
Standardization of herbals across studies: produces results that are valid, reliable, comparable & reproducible.
Regulation of herbals as pharmaceutical-grade: “Reluctance to use it [honey] until regulated products were available” (Cooper, 2008).
Risks vs. Benefits: Medihoney is regulated by the FDA; safe, and comparable in efficacy& safety to existing products. Gamma-irradiation eliminates pathogens (e.g. botulism).

21. Expert & Literature Reviews
The Adulteration of Essential Oils and The Consequences to Aromatherapy and Natural Perfumery Practice: Part 1 Oil Adulteration (Burfield, 2003).
Nursing As A Context For Alternative & Complementary Modalities (Frisch, 2001).
Using Honey to Inhibit Wound Pathogens (Cooper, 2008)

22. Unsystematic Clinical Observation
Suffrage cause by MRSA “Single unit[s] within the context of its real-life Environment… as an understanding of the situation begins to emerge, other questions arise and new data maybe gathered to address new questions…[about] the multiplicity of factors that influences patient care” (Burns & Grove, 2009, p 519).

23. Unsystematic Clinical Observation
Clinical “narrative” mode explores/documents:
Clinical judgment
experiential learning
Chronology of unfolding events & responses
Concerns of patient & provider
Nuances of ethically driven care by nurses

24. Unsystematic Clinical Observations
2 Clinical Narratives on fulminating MRSA:
psychosocial burdens on Patient: fear, depression, hopelessness, helplessness, impaired QoL.
psychosocial burdens on Provider: protraction, ambiguity & uncertainty of intervention(s).

25. Epidemiological Protocols & Practice
Prevention: A Health Promotion & Disease Prevention protocol for MRSA in primary care.
Intervention: Can Manuka herbals reduce the incidence & prevalence of MRSA colonization, morbidity, mortality, and suffrage?
Prognosis: Surveillance of at risk populations in the primary care setting (not during acute or outpatient encounters)

26. Epidemiological Protocols & Practice
Methicillin Resistant Staphylococcus Aureus (MRSA) Best Practices Guidelines for Hospitals. (Arnold et al, 2001).
National Nosocomial Infections Surveillance System (2004).
Wide Variation in Adoption of Screening and Infection Control Interventions for Multidrug Resistant Organisms (Pogorzelska, Stone & Larson, 2012).

27. Part III: Evidence-based Quality Improvement (EBQI)

28. Who is at Risk For MRSA?
Inmates are at risk for community-acquired MRSA (CA-MRSA).
frequent reason for seeking care.
Presents like an insect bite if on the skin.
Occurs in waves of outbreaks.

29. Environment, Preferences & Values
Nursing & Medical protocol for MRSA:
Consistent with the National Clearing House Guideline for soft tissue lesions due to CA-MRSA
Nursing determines if inmate needs referral to the APN or MD:
I/M usually do not experience the severe or life-threatening sequels associated with other types of MRSA.

30. Ethics
Inmates are a vulnerable population: special care that EBQI does not become clinical research.
Inmates are wards of the state: all services are highly regulated & standardized across the board.
The fair & equal distribution of resources: unethical to implement an EBQI in one facility while continuing with traditional practice (or no treatment) in another.

31. Obstacles
Change in corrections is complex: county & state regulations; national & international
subcontractors.
Publically-financed services: cost-containment, limited formulary, no infection control (IC) nurse.
Other reasons for & types of MRSA: abscesses from IV drug use, hospital-acquired MRSA, etc.

32. Accessible Resources
US Department of Labor, Federal Bureau of Prisons Clinical Practice “Evidence Based Guideline Reference” book & online database: Corrections Medical Services- Clinic All-In-Ones (or medical pathways) for MRSA.
Web-based epidemiological/IC information: Clinical Practice Guidelines by The Infectious Diseases Society of America for the Treatment of Methicillin-resistant Staphylococcus Aureus Infections in Adults and Children.
This EBQI project: studies related to management of CA-MRSA with Manuka Herbals.

33. Needed Resources
IC nurse: primary care, health maintenance & prevention, MDRO IC recommendations, MRSA epidemiological trends.
Baseline documentation: charts, analysis, reports
Team: IC nurse, APN/ MD to plan and set EBQI goal & proposal.

34. Goal
Reduced the incidence & prevalence of CA MRSA in the detention facility.

35. Strategy/Method/Plan
Formulary: Medihoney ointment KOP for CA-MRSA lesions. Medihoney dressings for STI & wounds due to CA-MRSA.
Self-care: Topical sundry product(s) (soap & treatment gel) available to help prevent CA-MRSA (in-vivo product research still needed per PICOT question in Part II).

36. Responsibility 6 months
Review & summarize: literature, practices of other facilities/ entities/ disciplines on MDRO IC.
RCA of Studies: Manuka herbals/ Medihoney for CA-MRSA
Review Current Practice: Clinic All-In-Ones, and Nursing Protocol for MRSA.
Design/ Redesign Education: pamphlet & PowerPoint on preventing CA-MRSA.
Cost-analysis: proposed intervention(s) vs. current practice

37. Outcomes 1 year Fewer clinic visits per month for MRSA lesions.
Fewer referrals to APN/MD/ for oral antibiotics for soft tissue infections (STI) due to MRSA.
Fewer referrals to the hospital for IV antibiotics and other interventions for invasive MRSA STI, and other types of wounds (e.g. diabetic ulcers)
Shorter times to healing of of these lesions & infections.

38. Measures of Effectiveness of EBQI
1. Cure/Response Vs. Treatment Failure/ NNT vs. NNH: per outcome goals 2. Relapse Rate: Recurrent MRSA in inmates and/or Occurrence of MRSA in the cellmate of someone with MRSA and/or outbreak in a housing unit 3. Development of Resistance to/ Adverse Effects of Therapy: studies in this EBP project on Manuka Herbals vs standard intervention. 4. Sensitivity & Specificity of Monitoring: lab technology 5. Morbidity & Mortality: compare to statistics / trends on MRSA from the Center for Disease Control Notifiable Disease Reporting System, and the National Nosocomial Infection Surveillance (NNIS).

39. References
Alcaraz, A., Kelly, J. (2002). Treatment of an infected venous leg ulcer with honey dressings. British Journal of Nursing, 11, , Arnold, M., Dempsey, J., Fishman, M., McAuley, P., Tibert, C., Vallande, N. (2001). Methicillin resistant staphylococcus aureus (MRSA) best practices guidelines for hospitals. Infection Control Professionals of Southern New England. Retrieved from Barrett,B., Marchand, L., Scheder, J., Plane, M., Maberry, R., Appelbaum, D., Rakel, D., Rabago, D. (2003). Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine. The Journal Of Alternative and Complementary Medicine, 9(6),

40. References
Burfield, T. (2003). The adulteration of essential oils and the consequences to aromatherapy and natural perfumery practice. Presentation to the International Federation of Aromatherapists Annual AGM. London. Retrieved fromhttp:// Burns, N., & Grove, S. (2009). The practice of nursing research: Appraisal, synthesis, and generation of evidence. St. Louis, MO: Elsevier, Inc. Cooke, A., & Cooke M. (2001) Cawthron Report No. 263: An investigation into the antimicrobial properties of manuka and kanuka oil. Prepared for Tairawhiti Pharmaceuticals. Retrieved from Cooper, R. (2008). Using honey to inhibit wound pathogens. Nursing Times, 104(3), 46, 48, 49.

41. References
Edwards-Jones, V., Buck, R., Shacross, S., Dawson, M., Dunn, K. (2004). The effect of essential oils on methicillin-resistant Staphylococcus aureus using a dressing model. Burns, 30(8), Retrieved fromhttp:// ntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum Frisch, N. (2001). Nursing as a context for alternative/complementary modalities. Journal of Issues in Nursing, 6. Retrieved athttp://

42. References
Gethin G., Cowman, S. (2008)Bacteriological changes in sloughy venous leg ulcers treated with manuka honey or hydrogel: an RCT (89kb). Journal of Wound Care, 17(6), 241 – 247. Retrieved fromhttp:// Lie, D., & Boker, J. (2006). Comparative survey of Complementary and Alternative Medicine (CAM) attitudes, use, and information-seeking behavior among medical students, residents & faculty. BMC Medical Education. Retrieved from /6/58/prepub.

43. References
Melnyk, B. & Fineout-Overholt, E. (2011) Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice (2nd Ed.). Lippincott Williams & Wilkins. Natarajan, S., Williamson, D, Grey J., Harding K., & Cooper, R. (2001). Healing of an MRSA colonized, hydroxyurea-induced leg ulcer with honey. Journal of Dermatological Treatment, 12, 33–36. Retrieved fromhttp://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=740c39e9-8dd3-4d76 9c4a143bfa0f331a%40sessionmgr104&vid=2&hid=110

44. References
National Nosocomial Infections Surveillance System (2004). Report: data summary, January June American Journal of Infection Control. Retrieved from Pogorzelska, M., Stone, P., Larson, E. (2012). Wide variation in adoption of screening and infection control interventions for multidrug resistant organisms: A national study. American Journal of Infection Control, 40(8), Retrieved from Program for Integrative Medicine & Health Care Disparities at Boston Medical Center. Our mission. Retrieved from

45. References
Schneider, C., Meek, P., Bell, I. (2003). Development and validation of IMAQ: Integrative medicine attitude questionnaire. BMC Medical Education, 3(5). Retrieved from