Abstract Case Report

A 26-yr-old female African elephant (Loxodonta africana) received a deep laceration to the neck from the tusk of another elephant. The wound originated approximately 10 cm caudal to the middle of the right pinna, extended ventromedially, and penetrated multiple muscle layers. The wound was approximately 10–12 cm wide and 25–30 cm deep.

Initial treatment involved wound lavage with sterile saline twice daily, sulfadimethoxine/ormetoprim (Primor®, Pfizer Animal Health, Exton, Pennsylvania, USA; 8.5 mg/kg p.o., b.i.d.), and ibuprofen (Pharmacia and Upjohn, Kalamazoo, Michigan, USA; 2 mg/kg p.o., b.i.d. as needed). There was purulent discharge from the wound on day 5, therefore topical wound dressing was initiated. After wound lavage, the wound cavity was packed with laparotomy sponges coated with a 1:1 mixture of 1% silver sulfadiazine cream (BASF Corporation, Mount Olive, New Jersey, USA) and an anti-inflammatory ointment (hemorrhoidal ointment, CVS Pharmacy Inc., Woonsocket, Rhode Island, USA). Despite aggressive topical and systemic therapy, the wound became progressively more purulent, necrotic, and malodorous. On day 11, the wound dressing was changed from silver sulfadiazine cream/hemorrhoidal ointment to laparotomy sponges coated with unpasteurized honey (Eisele’s Raw Honey, Westfield, Indiana, USA). On day 16, oral antibiotics were changed from sulfadimethoxine/ormetoprim to enrofloxacin (Baytril®, Bayer Corporation, Shawnee Mission, Kansas, USA; 1.5 mg/kg p.o., s.i.d.) based on culture and sensitivity results. After 5 wk of therapy (day 51), enrofloxacin was discontinued due to poor patient compliance. Wound care from day 52 until completion of healing (12 additional weeks) consisted of twice daily wound lavage and dressing with unpasteurized honey. By day 101, wound care was decreased to once daily. On day 138 wound care was discontinued, and on day 143 the wound was considered healed.

Within 4 days of beginning topical treatment with honey, subjective scores of purulent exudate, necrotic tissue, and malodor began to improve. By day 29, the wound was no longer malodorous. Minimal necrotic tissue remained in the wound on day 37, and purulent discharge had resolved by day 90.

A single-dose oral enrofloxacin pharmacokinetic study was performed to evaluate serum and milk levels of the drug. Following oral administration of enrofloxacin at 1.5 mg/kg, serum levels were subtherapeutic at all time points over 24 hr.

Discussion

Unpasteurized, or raw, honey has been used as a medicine for centuries. Many ancient cultures used honey to treat skin wounds, gastric ulcers, diarrhea, eye disorders, and cough.⁷ There are many reports in the human medical literature of wound dressing with unpasteurized honey, but there are very few reports of its use in clinical veterinary medicine.^4,5

The success of unpasteurized honey as a wound dressing is due to its antibacterial, anti-inflammatory, immune-stimulating, tissue-debriding, and tissue-nourishing properties. High osmolality, phytochemicals, production of hydrogen peroxide, and stimulation of leukocyte activity contribute to the overall antibacterial activity of honey. Raw honey reduces inflammation by eliminating bacterial production of pro-inflammatory antigens and cytotoxins⁸, reducing local edema by osmosis⁶, and contributing antioxidants that scavenge free radicals². Immune system stimulation includes activation of neutrophils, stimulation of lymphocyte proliferation¹, and release of immune-mediator compounds by monocytes¹¹. Dressing wounds with raw honey often eliminates the need for surgical debridement.¹⁰ Honey improves tissue regeneration by stimulating the development of new capillary beds, thereby increasing nutrient delivery and oxygen supply to tissues.^3,6 Raw honey also provides the moist environment necessary for proliferation of epithelial cells and fibroblasts.⁸

Honey is easy to use as a wound dressing. It can be spread directly onto wounds, soaked into gauze, or used to fill cavities. It generally causes no pain upon application.⁷ Plasma or lymph is drawn out of tissues by osmosis, creating a layer of dilute honey in contact with the wound surface; there is minimal adhesion of bandage materials to cause pain or tissue damage when dressings are changed.⁶ Honey dressings can be changed daily, but can be changed more frequently if the wound is infected or contaminated; bandages can be changed less frequently if the wound is clean and dry.⁶ Any residual honey is easily removed with warm water. Solidified honey can be returned to the liquid form by warming to 37°C. Honey should not be heated excessively because the enzyme that produces hydrogen peroxide is easily inactivated by heat.⁶ Although honey may contain clostridial spores, there are no published reports of wound botulism.

In this case, no adverse effects resulted from using unpasteurized honey as a wound dressing. Necrosis and malodor were greatly decreased within 16 days and purulent discharge was drastically reduced within 23 days of beginning treatment with honey. Subjectively, the wound healed faster and with less scar tissue than expected for this elephant as well as in comparison to wounds in other elephants. Raw honey likely provided the primary antibacterial activity during wound healing since enrofloxacin serum levels were subtherapeutic. Unpasteurized honey should be considered for topical treatment of deep, infected wounds in elephants.

Acknowledgments

The authors thank Ellen Clark, RVT, Jennifer Niederlander, RVT, David Hagan, Barre Fields, Don Nevitt, Jill Sampson, Leslie Mackie, Adam Cheek, Niki Jordan, and Shea Earley for assistance with wound management, and Susan Mikota, DVM for consultation regarding the case.

Literature Cited

1.  Abuharfeil N, R Al-Oran, M Abo-Shehada. 1999. The effect of bee honey on the proliferative activity of human B- and T-lymphocytes and the activity of phagocytes. Food Agric. Immunol. 11: 169–177.

2.  Frankel S, GE Robinson, MR Berenbaum. 1998. Antioxidant capacity and correlated characteristics of 14 unifloral honeys. J. Apicultural Res. 37(1): 27–31.

3.  Gupta SK, H Singh, AC Varshney, P Prakash. 1992. Therapeutic efficacy of honey in infected wounds in buffaloes. Indian J. of Ani. Sci. 62(6): 521–523.

4.  Harcourt-Brown FM. 2002. Honey to treat rabbit abscesses. Exotic DVM. 3(6): 13–14.

5.  Mathews KA, AG Binnington. 2002. Wound management using honey. Compend. Contin. Educ. Pract. Vet. 24(1): 53–60.

6.  Molan PC. 1998. A brief review of the use of honey as a clinical dressing. Primary Intention Aust. J. Wound Manage. 6(4): 148–158.

7.  Molan PC. 1999. Why honey is effective as a medicine. 1. Its use in modern medicine. Bee World. 80(2): 80–92.

8.  Molan PC. 2001a. Why honey is effective as a medicine. 2. The scientific explanation of its effects. Bee World. 82(1): 22–40.

9.  Molan PC. 2001b. Honey as a topical antibacterial agent for treatment of infected wounds. World Wide Wounds. www.worldwidewounds.com.

10.  Subrahmanyam M. 1993. Topical application of honey in treatment of burns. Br. J. Surg. 78(4): 497–498.

11.  Tonks A, RA Cooper, AJ Price, PC Molan, KP Jones. 2001. Stimulation of TNF-α release in monocytes by honey. Cytokine. 14(4): 240–242.