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• RN. BSN
  Suzanne P. Hall
  Published on: 23 March 2021
• The issues with promoting honey over antibiotics
  Lucy Dale, Ellie V Evans
  Published on: 23 March 2021
• Honey and in vitro antibacterial properties including Helicobacter pylori
  Mahbub M. Chowdhury
  Published on: 23 March 2021
• Symptomatic relief or Cure?
  Arvind Joshi
  Published on: 23 March 2021
• Honey! Go for the Cure!
  Arvind Joshi
  Published on: 23 March 2021

• Published on: 23 March 2021

  RN. BSN

  • Suzanne P. Hall, Health care consultant and teaching staff for a preschool age population 2-6 years Shadyside Presbyterian Church Nursery School of Pittsburgh . PA., USA

  It would be helpful if it assessed the standard administration quantitatively and specific frequency utilized in the study ‘s participants , or related studies , At the very least - providing a link to the exact dosing used in this study as a reference point would be beneficial .

  Conflict of Interest:
  None declared.

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• Published on: 23 March 2021

  The issues with promoting honey over antibiotics

  • Lucy Dale, Final Year Medical Student Barts & the London School of Medicine & Dentistry
  • Other Contributors:
    • Ellie V Evans, Final Year Medical Student

  To the editor,

  We read the article “Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis” with great interest. The need to discover effective remedies for symptomatic relief of upper respiratory tract infections (URTIs), while preventing further antimicrobial resistance developing is indeed paramount. However, after reading the article in detail, we noted a number of discrepancies which we feel must be highlighted and addressed.

  Firstly, we believe that the article is misleading, and if read as a lay member of the public, or indeed by a sensationalist news outlet, incorrect and potentially health-threatening conclusions may be drawn and promoted. Firstly, the abstract focuses on positing honey as an alternative to antibiotics for the symptomatic relief of URTIs. The authors highlight that honey possesses antimicrobial properties, with the conclusion of the abstract affirming that it is a “widely available and cheap alternative to antibiotics”. The abstract also concludes that honey improves symptoms in comparison with “usual care”, which, left hitherto unspecified, and paired with the aforementioned focus on a comparison between honey and antibiotics, again augments the misleading introduction to the article. Fundamentally, none of the 14 the studies included within the systematic review compare the use of honey with the use of antibiotics. Focusing so strongly on comparing honey to antib...

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  To the editor,

  We read the article “Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis” with great interest. The need to discover effective remedies for symptomatic relief of upper respiratory tract infections (URTIs), while preventing further antimicrobial resistance developing is indeed paramount. However, after reading the article in detail, we noted a number of discrepancies which we feel must be highlighted and addressed.

  Firstly, we believe that the article is misleading, and if read as a lay member of the public, or indeed by a sensationalist news outlet, incorrect and potentially health-threatening conclusions may be drawn and promoted. Firstly, the abstract focuses on positing honey as an alternative to antibiotics for the symptomatic relief of URTIs. The authors highlight that honey possesses antimicrobial properties, with the conclusion of the abstract affirming that it is a “widely available and cheap alternative to antibiotics”. The abstract also concludes that honey improves symptoms in comparison with “usual care”, which, left hitherto unspecified, and paired with the aforementioned focus on a comparison between honey and antibiotics, again augments the misleading introduction to the article. Fundamentally, none of the 14 the studies included within the systematic review compare the use of honey with the use of antibiotics. Focusing so strongly on comparing honey to antibiotics, both within the abstract and throughout the article, with the conclusion stating that authors “would recommend honey as an alternative to antibiotics”, is unjustified, and may have potentially dangerous implications for those misled by the statements.

  The statements regarding antibiotics themselves are also both vague and misleading. Authors state that “the use of antibiotics for URTIs is a particular problem, because they are ineffective”, which, as a sweeping statement, is highly inaccurate. The claim that antibiotics are “associated with significant adverse effects in children and adults” is also imprecise and over-generalised, again contributing to the article’s potential to both misinform readers and promote scaremongering. We also feel there should also be more clarity with regards to the age restrictions surrounding the therapeutic recommendations for honey. While the authors briefly mention within their discussion that honey is not commercially safe for those who are allergic and infants under 1 years old, there is no mention of any age limitations within the introduction and conclusion section of this statement being made.

  It must be noted that the studies included within the systematic review contain high levels of bias, which limits both the reliability of the results and the conclusions made. For instance, authors utilise the Cochrane risk of bias tool, which states that the overall risk of bias for each article is the lowest favourable assessment of all domains [1]. Therefore, according to Figure 2 of the article, a “Summary of risk of bias assessment for included studies” - for which no key is provided - 9 of the studies are classified as having a ‘high risk’ of bias, with 5 classified as having ‘some concerns’. This is contrary to what is stated in the article; authors claim that two articles were at ‘low risk’ of bias, with the overall risk of bias being ‘moderate’. Authors therefore seem to have assigned a lower level of bias to the studies than classified by the Cochrane risk of bias tool, which, paired with the fact that the majority of the studies included have a high risk of bias, further acts to decrease the reliability of the conclusions made. Additionally, the high level of disparity between the variables within the studies decreases the validity of the conclusions even further. There are over 14 variations of interventions, and 10 variations of comparators, between the 14 studies. This high level of bias and variability amongst the studies included thus renders the findings of the systematic review, and therefore the ability to
  judge the efficacy of honey on URTIs, highly limited.

  Furthermore, it is important to maintain appropriate antimicrobial stewardship when practicing medicine. However, this article provides little delineation as to what particular organisms honey would be effective against. For instance, not all members of the public will be aware that antibiotics are ineffective against viral infections. Whilst the authors state “the majority of URTI’s are viral, therefore antibiotics would be ineffective” – there is little mention with regards to bacterial, fungal or helminthic organisms – and the vagueness of the statement above could be considered misleading. Having shown this article to persons of a non-medical background, it became obvious that there was a lack of clarity, creating confusion as to whether honey should be used for all organisms, or just viral ones. Additionally, the National Institute of Clinical Excellence (NICE) recommends Phenoxymethylpenicillin or Clarithromycin/Erythromycin for the treatment of patients with suspected bacterial URTIs, who score high enough using the FeverPAIN or Centor score [2]. Readers of this paper may wrongly be given the impression that honey supersedes the use of antibiotics for any infection, and therefore treat themselves or others in their care as such. With some infections, such as streptococcus, having the potential to cause significant morbidity if left untreated by antibiotics [3], the misinformation within this article could lead to the development of rheumatic fever and cardiac complications later in life.

  Ultimately, our aforementioned points; the lack of clarity throughout the article, the bias within each study, and the significant variability between the studies’ variables combine to create a misleading article, with potentially damaging consequences for the lay public. Dangerous decisions could ultimately be made, with our main concern being that people may delay seeking appropriate medical help for a condition for which honey is ultimately not the appropriate treatment; in turn this could increase both morbidity and use of NHS resources. With the propensity for news outlets to grasp for controversial headlines, and promoting them in a further misleading and sensationalist manner, we feel that a more balanced argument needs to be put forward, in order for a responsible message on this interesting, pertinent topic to be conveyed.

  1. Chapter 8: Assessing risk of bias in a randomized trial | Cochrane Training. https://training.cochrane.org/handbook/current/chapter-08. Accessed October 2, 2020.
  2. Respiratory Tract Infections-Antibiotic Prescribing Prescribing of Antibiotics for Self-Limiting Respiratory Tract Infections in Adults and Children in Primary Care. www.nice.org.uk. Accessed October 2, 2020.
  3. Thompson KM, Sterkel AK, McBride JA, Corliss RF. The Shock of Strep: Rapid Deaths Due to Group a Streptococcus. Acad Forensic Pathol. 2018. doi:10.23907/2018.010

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  Conflict of Interest:
  None declared.

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• Published on: 23 March 2021

  Honey and in vitro antibacterial properties including Helicobacter pylori

  • Mahbub M. Chowdhury, Consultant Dermatologist University Hospital of Wales , Cardiff CF14 4XW

  I read with interest the latest evidence for honey and treatment of coughs which was also reported widely in the national press (1). Honey has been shown in laboratory in vitro studies to inhibit bacterial growth including Helicobacter pylori linked with dyspepsia and gastritis (2, 3). Concentrations between 10-20% honey has been shown to be effective against both Gram negative and Gram positive bacteria (3). My late father Professor MNH Chowdhury, a clinical bacteriologist, researched this in the 1990s and advocated Manuka honey especially for its healing and antibacterIal properties. Interestingly, the in vitro findings showed some isolates were resistant to various antimicrobial agents but honey inhibited these organisms also (3). Secondary bacterial infections may respond to this simple remedy after primary viral coughs and colds and need further clinical study.
  References
  1. Abuelgasim H, Albury C, Lee J. Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis. BMJ Evidence Based Med 2020, 18 Aug online; bmjebm-2020-111336.
  2. Rashed RS, Ayoola EA, Mofleh IA, Chowdhury MNH, Mahmood K, Faleh FZ. Helicobacter pylori and dyspepsia in an Arab population. Trop Geogr Med 1992; 44(4), 304-7.
  3. Ali AT, Chowdhury MNH, al Humayyad MS. Inhibitory effect of natural honey on Helicobacter pylori. Trop Gastroenterol 1991; 12(3), 139-43.

  Conflict of Interest:
  Reporting previous peer reviewed research done by family member 28-30 years ago.

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• Published on: 23 March 2021

  Symptomatic relief or Cure?

  • Arvind Joshi, Physician( Medicine and Therapeutics), Founder Convener and President Our Own Discussion Group. Our Own Discussion Group, Mumbai and Ruchi Diagnostic Center and Ruchi Clinical Laboratory, Kharghar.

  It is risky to propose that agent offering symptomatic relief should replace microbial cure. Two are different aspects and different approaches.
  Besides honey may not be considered entirely safe. Many environmental Journals are raising voice against contamination of honey either by microbes or by antimicrobials.
  Clinicians must know if the Upper Respiratory Infection is going to be entirely selflimited and will not progress to Pneumonia, or lead to late Sequelae like Rheumatic Fever Rheumatic Heart Disease.
  If only symptomatic relief is to be achieved, one wonders if home made sugar syrup may work as well as honey will. Moreover homemade sugar syrup will not carry microbes or antimicrobials!
  Arvind Joshi MBBS MD FCGP FAMS FICP.

  Conflict of Interest:
  None declared.

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• Published on: 23 March 2021

  Honey! Go for the Cure!

  • Arvind Joshi, Physician( Medicine and Therapeutics), Founder Convener and President: Our Own Discussion Group. Our Own Discussion Group, Ruchi Diagnostic Center and Ruchi Clinical Laboratory.

  The Editor
  Read with interest the article
  " Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis"
  Symptomatic relief and treatment of infections are entirely different treatment goals.
  A clinician must decide very clearly either on clinical grounds or with investigations, if the infection is going to be a selflimited one which will subside completely without any antimicrobial and also will not cause any late Sequelae. A very important example in this regards used to be Streptococcal throat infections which often would subside without proper antimicrobial treatment, only to cause Rheumatic Fever, Rheumatic Arthritis and Rheumatic Heart Disease later. Not necessarily upper respiratory tract infections, post Streptococcal Glomerulonephritis, post Rickettsial complications are some of the examples where not symptomatic relief, but prompt and adequuate treatment of infections with antimicrobials is crucial for preventing devastating Sequelae.
  It is often very difficult to to foresee which respiratory or for that matter any infection will be self limited and will not cause any serious Sequelae if no antimicrobials are used.
  That is the CATCH!
  Arvind Joshi;
  MBBS, MD; FCGP, FAMS;
  Founder Convener and President:
  Our Own Discussion Group,
  602-C, Megh Apartments,
  Ganesh Peth Lane, Dadar West;
  Mumbai PIN 400028;
  Consaltant...

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  The Editor
  Read with interest the article
  " Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis"
  Symptomatic relief and treatment of infections are entirely different treatment goals.
  A clinician must decide very clearly either on clinical grounds or with investigations, if the infection is going to be a selflimited one which will subside completely without any antimicrobial and also will not cause any late Sequelae. A very important example in this regards used to be Streptococcal throat infections which often would subside without proper antimicrobial treatment, only to cause Rheumatic Fever, Rheumatic Arthritis and Rheumatic Heart Disease later. Not necessarily upper respiratory tract infections, post Streptococcal Glomerulonephritis, post Rickettsial complications are some of the examples where not symptomatic relief, but prompt and adequuate treatment of infections with antimicrobials is crucial for preventing devastating Sequelae.
  It is often very difficult to to foresee which respiratory or for that matter any infection will be self limited and will not cause any serious Sequelae if no antimicrobials are used.
  That is the CATCH!
  Arvind Joshi;
  MBBS, MD; FCGP, FAMS;
  Founder Convener and President:
  Our Own Discussion Group,
  602-C, Megh Apartments,
  Ganesh Peth Lane, Dadar West;
  Mumbai PIN 400028;
  Consaltant Physician at Ruchi Diagnostic Center and Ruchi Clinical Laboratory, Sunshine CHS, Plot 58,
  Kharghar PIN 410210,
  Maharashtra State, INDIA.
  FICP

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  Conflict of Interest:
  None declared.

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