Promotion of Human Dermal Fibroblast Migration, Matrix Remodelling and Modification of Fibroblast Morphology within a Novel 3D Model by Lucilia sericata Larval Secretions

Use of biosurgery for the treatment of foot ulcers infected with therapy-resistant bacteria: a case report

Biosurgery (larval therapy) has been used for centuries. However, in recent times, this treatment has been replaced with the use of antibiotics for the treatment of wounds. Due to increasing antibiotic resistance, larval therapy is once again coming to the fore as an effective and efficient treatment. Due to the increasing ageing population, along with an increase in patients with arterial occlusive disease, diabetes and immobility, the number of patients with hard-to-heal wounds will increase. The stressors associated with wounds, such as pain, limited physical functionality, depression and social withdrawal, have a negative impact on patient quality of life. This case report documents the performance of biosurgery in a patient with multimorbidities.

Development of bioactive electrospun scaffolds suitable to support skin fibroblasts and release Lucilia sericata maggot excretion/secretion

Larval therapy has been reported to be beneficial in the treatment of chronic wounds by promoting granulation tissue formation, due to its antimicrobial properties and by degrading necrotic tissue. However, the use of live maggots is problematic for patient acceptance, and thus there is a need to develop materials which can release therapeutic biomolecules derived from maggot secretions to the wound bed. Here we describe the fabrication of a novel bioactive scaffold that can be loaded with Lucilia sericata maggot alimentary excretion/secretion fluids (L. sericata maggot E/S), and which can also provide structural stability for mammalian cell-growth and migration to support wound repair. Electrospun scaffolds were prepared from a poly(caprolactone)-poly(ethylene glycol)–block copolymer (PCL-b-PEG) blended with PCL with average fibre diameters of ~ 4 μm. The scaffolds were hydrophilic and were able to support viable fibroblasts that were able to infiltrate throughout the extent of the scaffold thickness. L. sericata maggot (E/S) was subsequently adsorbed to the surface and released over 21 days with retention of the protease activity that is responsible for supporting fibroblast migration. The incorporation of L. sericata maggot E/S on the surface of the electrospun fibres of PCL-PEG/PCL fibres is a novel approach with potential for future application to support skin wound healing within a clinical setting.

Anti-inflammatory and wound healing potential of medicinal maggot excretions/secretions at the ocular surface

PURPOSE

In the skin, Lucilia sericata maggot excretions/secretions (ES) accelerate wound healing and limit inflammation. This study aimed to determine whether ES have similar beneficial effects at the ocular surface.

METHODS

Human corneal epithelial cells (HCEC) were cultured with ES and cell viability was determined by the MTT assay. Additionally, mRNA expression of growth factors, antimicrobial peptides (AMPs) and cytokines was assessed by qPCR. ES ability to modulate TLR-induced IL-6 and IL-8 expression was determined by qPCR and ELISA. ES potential to promote corneal healing was evaluated in vitro by a migration assay in HCEC, and in vivo using a mouse model.

RESULTS

ES did not impair HCEC viability up to 25 μg/ml. Among the factors evaluated, only hBD-2 was upregulated (2.5-fold) by 1.5 μg/ml ES after 6 hrs (P = 0.04). In HCEC, ES reduced Poly I:C-induced IL-6 and IL-8 mRNA (P ≤ 0.001) and protein (P ≤ 0.0001) expression. A similar effect was observed with Flagellin (TLR5 agonist) but it was less robust for FSL-1 (TLR2/6 agonist) and Pam3CSK4 (TLR1/2 agonist). The greatest in vitro migration effect was observed with 6.2 μg/ml ES after 44 hrs where gap area compared to vehicle was 53.3 ± 3.7% vs. 72.6 ± 5.4% (P = 0.001). In the mouse model, the maximum healing effect was present with 1.5 μg/ml ES after 12 hrs with a wound area of 19.0 ± 2.7% vs. 60.1 ± 21.6% (P = 0.003) or 77% reduction of the wound area compared to the negative control.

CONCLUSIONS

ES significantly reduce in vitro TLR-induced production of inflammatory cytokines and promote corneal wound healing.

Antimicrobial-wound healing peptides: Dual-function molecules for the treatment of skin injuries

Chronic non-healing wounds caused by microbial infections extend the necessity for hospital care and constitute a public health problem and a great financial burden. Classic therapies include a wide range of approaches, from wound debridement to vascular surgery. Antimicrobial peptides (AMPs) are a preserved trait of the innate immune response among different animal species, with known effects on the immune system and microorganisms. Thus, AMPs may represent promising candidates for the treatment of chronic wounds with dual functionality in two of the main agents that lead to this condition, proliferation of microorganisms and uncontrolled inflammation. Here, our goal is to critically review AMPs with wound healing properties. We strongly believe that these dual-function peptides alone, or in combination with other wound healing strategies, constitute an underexplored field that researchers can take advantage of.

Wound healing and antibacterial activities of water-soluble chitosan nanoparticles and excretion/secretion as a natural combination from medicinal maggots, Lucilia cuprina

Wounds management takes a high interest in the medical field and the addition of antimicrobial agents in an assortment of wound dressings leads to delay the wound healing. This study aimed at preparing natural combination between excretion/secretion (ES) and water-soluble chitosan nanoparticles (from Lucilia cuprina maggots) and investigating its antibacterial and wound healing activities. ES of maggots was collected, and the water-soluble chitosan nanoparticles (WSCNPs) were prepared and characterized. Antibacterial activities of combinations were evaluated against Staphylococcus aureus, Bacillus subtilis, Escherichia coli, and Proteus vulgaris. ES-WSC-2 combination that contains 50% ES and 1% WSCNPs showed highest antibacterial activity against all tested bacteria compared to the other combinations. In vitro, the ES-WSC-2 combination was used to study the wound healing activity by scratch assay. The synergism between ES and WSCNPs (in ES-WSC-2 combination) accelerated the wound healing rate which suggests the use of this combination as an effective natural antibacterial and wound healing agent.

The effect of Lucilia sericata larval excretion/secretion (ES) products on cellular responses in wound healing

Chronic wounds are still regarded as a serious public health concern, which are on the increase mainly due to the changes in life styles and aging of the human population. There are different types of chronic wounds, each of which requires slightly different treatment strategies. Nevertheless, wound bed preparation is included in treatment of all types of chronic wounds and involves tissue debridement, inflammation, and infection control, as well as moisture balance and epithelial edge advancement. Maggot therapy (MT) is a form of biological debridement which involves the application of live medical grade Lucilia sericata (Meigen, 1826) (Diptera: Calliphoridae) larvae. Whereas it was initially thought to act mainly through debridement, today MT is known to influence all four overlapping physiological phases of wound repair: homeostasis, inflammation, proliferation, and remodelling/maturing. During MT, medical-grade larvae are applied either freely or enclosed in tea-bag like devices (biobag) inside the wounds, which suggests that larva excretion/secretion (ES) products can facilitate the healing processes directly without the need of direct contact with the larvae. This review summarizes the relevant literature on ES-mediated effects on the cellular responses involved in wound healing.

A molecular approach to maggot debridement therapy with Lucilia sericata and its excretions/secretions in wound healing

Chronic wounds caused by underlying physiological causes such as diabetic wounds, pressure ulcers, venous leg ulcers and infected wounds affect a significant portion of the population. In order to treat chronic wounds, a strong debridement, removal of necrotic tissue, elimination of infection and stimulation of granulation tissue are required. Maggot debridement therapy (MDT), which is an alternative treatment method based on history, has been used quite widely. MDT is an efficient, simple, cost-effective and reliable biosurgery method using mostly larvae of Lucilia sericata fly species. Larvae can both physically remove necrotic tissue from the wound site and stimulate wound healing by activating molecular processes in the wound area through the enzymes they secrete. The larvae can stimulate wound healing by activating molecular processes in the wound area through enzymes in their excretions/secretions (ES). Studies have shown that ES has antibacterial, antifungal, anti-inflammatory, angiogenic, proliferative, hemostatic and tissue-regenerating effects both in vivo and in vitro. It is suggested that these effects stimulate wound healing and accelerate wound healing by initiating a direct signal cascade with cells in the wound area. However, the enzymes and peptides in ES are mostly still undefined. Examining the molecular content of ES and the biological effects of these ingredients is quite important to illuminate the molecular mechanism underlying MDT. More importantly, ES has the potential to have positive effects on wound healing and to be used more as a therapeutic agent in the future, so it can be applied as an alternative to MDT in wound healing.

Dermal fibroblasts cultured from donors with type 2 diabetes mellitus retain an epigenetic memory associated with poor wound healing responses

The prevalence of Type 2 diabetes mellitus (T2DM) is escalating globally. Patients suffer from multiple complications including the development of chronic wounds that can lead to amputation. These wounds are characterised by an inflammatory environment including elevated tumour necrosis factor alpha (TNF-α). Dermal fibroblasts (DF) are critical for effective wound healing, so we sought to establish whether there were any differences in DF cultured from T2DM donors or those without diabetes (ND-DF). ND- and T2DM-DF when cultured similarly in vitro secreted comparable concentrations of TNF-α. Functionally, pre-treatment with TNF-α reduced the proliferation of ND-DF and transiently altered ND-DF morphology; however, T2DM-DF were resistant to these TNF-α induced changes. In contrast, TNF-α inhibited ND- and T2DM-DF migration and matrix metalloprotease expression to the same degree, although T2DM-DF expressed significantly higher levels of tissue inhibitor of metalloproteases (TIMP)-2. Finally, TNF-α significantly increased the secretion of pro-inflammatory cytokines (including CCL2, CXCL1 and SERPINE1) in ND-DF, whilst this effect in T2DM-DF was blunted, presumably due to the tendency to higher baseline pro-inflammatory cytokine expression observed in this cell type. Collectively, these data demonstrate that T2DM-DF exhibit a selective loss of responsiveness to TNF-α, particularly regarding proliferative and secretory functions. This highlights important phenotypic changes in T2DM-DF that may explain the susceptibility to chronic wounds in these patients.

Microphysiological systems for the modeling of wound healing and evaluation of pro-healing therapies

Wound healing is a multivariate process involving the coordinated response of numerous proteins and cell types. Accordingly, biomedical research has seen an increased adoption of the use of in vitro wound healing assays with complexity beyond that offered by traditional well-plate constructs. These microphysiological systems (MPS) seek to recapitulate one or more physiological features of the in vivo microenvironment, while retaining the analytical capacity of more reductionist assays. Design efforts to achieve relevant wound healing physiology include the use of dynamic perfusion over static culture, the incorporation of multiple cell types, the arrangement of cells in three dimensions, the addition of biomechanically and biochemically relevant hydrogels, and combinations thereof. This review provides a brief overview of the wound healing process and in vivo assays, and we critically review the current state of MPS and supporting technologies for modelling and studying wound healing. We distinguish between MPS that seek to inform a particular phase of wound healing, and constructs that have the potential to inform multiple phases of wound healing. This distinction is a product of whether analysis of a particular process is prioritized, or a particular physiology is prioritized, during design. Material selection is emphasized throughout, and relevant fabrication techniques discussed.

Maggot excretions/secretions promote diabetic wound angiogenesis via miR18a/19a - TSP-1 axis

AIMS

The impaired angiogenesis is one of the main factors affecting the healing of diabetic foot ulcer (DFU) wounds. Maggot debridement therapy (MDT) promotes granulation tissue growth and angiogenesis during DFU wound healing. Non-coding microRNAs can also promote local angiogenesis in DFU wounds by regulating wound repairing related gene expression. The purpose of this study was to investigate the mechanism of microRNAs in MDT promoting DFU wound angiogenesis.

METHODS

In this study, we applied MDT to treat DFU wound tissue and detect the expression of the miR-17-92 cluster. In vitro experiments, human umbilical vein endothelial cells (HUVECs) were treated with maggot excretions/secretions (ES), the miR-17-92 cluster and the predicted target gene expression were measured. Tube formation assay and cell scratch assay were performed when inhibition of miR-18a/19a or overexpression of thrombospondin-1 (TSP-1) were used in this study.

RESULTS

miR-18a/19a transcription significantly up-regulated and TSP-1 expression down-regulated in patients wound tissue and in HUVECs. Inhibition of miR-18a/19a or overexpression of TSP-1 partially blocked the migration and tube formation ability stimulated by ES.

CONCLUSION

Targeted activation of miR-18a/19a transcription levels and subsequent regulation of TSP-1 expression may be a novel therapeutic strategy for DFU.

Effectiveness of Chronic Wound Debridement with the Use of Larvae of Lucilia Sericata

The process of successful wound healing depends on effective debridement and infection control. One method of wound debridement, known since antiquity, is based on the use of fly larvae. Solid scientific evidence proves that maggot debridement therapy (MDT), like surgical intervention, can be effectively and safely used to remove necrotic tissue. Based on a review of the related literature, this study was designed to assess the effectiveness of chronic wound cleansing with the use of larvae of Lucilia sericata (Phaenicia sericata). Maggot therapy, applied in wound debridement and treatment, is a safe and effective method. Its benefits are associated with debridement, disinfection and faster tissue growth. MDT may reduce the duration of antibiotic therapy and the need for hospitalization, or it may decrease the number of outpatient visits required. It is a relatively cost-effective method, and, in addition to financial gains, it may reduce the frequency of inpatient treatment. In the literature, an increasing amount of scientific evidence confirms that such treatment can effectively reduce the biofilm and bacterial load in a wound.

Efficacy of a Ceratothoa oestroides Olive Oil Extract in Patients With Chronic Ulcers: A Pilot Study

Chronic wounds unresponsive to existing treatments constitute a serious disease burden. Factors that contribute to the pathogenesis of chronic ulcers include oxidative stress, comorbid microbial infections, and the type of immune system response. Preclinically, and in a case study, a formulation containing a Ceratothoa oestroides olive oil extract promoted wound healing. Patients with chronic venous and pressure ulcers, clinically assessed as being unresponsive to healing agents, were treated for 3 months with an ointment containing the C oestroides extract combined with antibiotic and/or antiseptic agents chosen according to the type of bacterial infection. Treatment evaluation was performed using the Bates-Jensen criteria with +WoundDesk and MOWA cell phone applications. After 3 months of treatment, C oestroides resulted in an average decrease of 36% in the Bates-Jensen score of ulcers ( P < .000), with the decrease being significant from the first month ( P < .007). The combined use of topically applied antibiotics and antiseptics efficiently controlled microbial ulcer infection and facilitated wound healing. In relation to other factors such as initial wound size, chronicity appeared to be an important prognostic factor regarding the extent of wound healing. Future clinical investigations assessing the wound healing efficacy of the C oestroides olive oil extract are warranted.

What is the optimal treatment time for larval therapy? A study on incubation time and tissue debridement by bagged maggots of the greenbottle fly, Lucilia sericata

The effective use of larvae of the greenbottle fly, Lucilia sericata, in wound debridement requires a working knowledge of how feeding changes over time. Using a laboratory assay and bagged larval dressings, the effect of incubation time on larval feeding rates and body mass was investigated for up to 120 hours at 32°C. The mass of tissue digested increased significantly in incremental 24-hour periods up to 72 hours, with no significant consumption occurring afterwards. Larval mass increased only up to 48 hours. A further test comparing the efficacy of a single 96-hour application of larvae against two consecutive 48-hour applications found that the mass of tissue digested in the latter was 14.3% higher than the former, a difference that was statistically significant. Current clinical guidance suggests a 4-day application period for bagged larvae. Based on these results, an incubation time of 72 hours (3 days) for bagged larvae would be the most effective at the study temperature. However, it is acknowledged that wound temperature can vary, whereby feeding rates would likely differ. In view of this, we conclude that a period of 3 to 4 days is optimum for the application of larvae, and current guidelines should be adhered to.

Maggot Therapy in Angiopathic Leg Ulcers: A Systematic Review and Meta-Analysis

Maggot therapy (MT) is a biological debridement tool using blowfly larvae to digest necrotic tissue as its food. In addition, maggot secretion contains several peptides that has antibacterial effect and healing stimulants that might enhance wound healing. Clinical outcomes from previous meta-analyses demonstrated benefit of MT, but results were highly heterogeneous. We have conducted an updated systematic review and meta-analysis with clearly defined clinical outcomes according to mechanism of MT including successful debridement, healing rate, and time to heal. Furthermore, our study was the first meta-analysis that reported wound-related pain between MT and conventional therapy. MEDLINE and Scopus were searched for comparative studies of MT and conventional therapy. Ten studies were eligible, of which 5 studies were angiopathic (venous or mixed arteriovenous ulcers) and the other 5 were diabetic foot ulcer. The MT had significant higher rate of successful debridement with risk ratio of 2.3 (95% confidence interval = 1.7-3.0) with low heterogeneity. Time to heal was about 3.1 weeks (95% confidence interval = 1.2-5.0), significantly shorter in MT but with high heterogeneity. Healing rate and pain were not significantly different between groups with high heterogeneity. In conclusion, MT was an effective debridement tool compared with conventional therapy. More studies should be done to confirm other findings because of high heterogeneity.

Pharmacological Properties of the Medical Maggot: A Novel Therapy Overview

In the last decade, maggot has been hailed as the miraculous “medicinal maggot” for its diverse properties, including antimicrobial, antibiofilm, anti-inflammatory, and wound healing activities. The fact that maggots show so many beneficial properties has increased the interest in these tiny larvae dramatically. Whilst there is relatively abundant clinical evidence to demonstrate the success of maggots as debridement agents, not so much emphasis has been placed on the basic science evidence, which was a combination of physical and biochemical actions. This review differs from those earlier works in that it is undertaken to provide an update of the latest scientific basis published on maggot, particularly active ingredients within maggot excretions/secretions (ES). Further investigations should focus on the isolation, identification, recombination, transgenosis, and mass production of the beneficial molecules within maggots.

The transcriptional responses of cultured wound cells to the excretions and secretions of medicinal Lucilia sericata larvae

Maggots, through their excretions and secretions (ES), promote wound healing by removing necrotic tissue, counter bacterial infection, and activate wound associated cells. We investigated the effects of a physiological dose of maggot ES on four wound-associated cell types in vitro with Affymetrix gene expression arrays; keratinocytes, endothelial cells, fibroblasts, and monocytes. Keratinocytes showed the fewest (n = 5; p < 0.05, fold-change ±2) and smallest fold-changes (up to 2.32×) in gene expression and conversely THP1 monocytes had the most (n = 233) and greatest magnitude (up to 44.3×). There were no genes that were altered in all four cell-lines. Gene pathway analysis identified an enrichment of immune response pathways in three of the treated cell-lines. Analyses by quantitative RT-PCR found many genes dynamically expressed in ES dose dependent manner during the three day treatments. Phenotype analyses, however, found no effects of ES on cell viability, proliferation, migration and angiogenesis. ES was 100× less potent at triggering IL-8 secretion than fibroblasts treated with purified bacterial lipopolysaccharide (LPS; in equivalent amounts to that found in ES; ∼40 EU/ml). Furthermore, co-treatment with LPS and ES decreased the LPS-alone triggered IL-8 secretion by 13%. Although ES had no direct effect on wound cell phenotypes it did partially reduce the immune response to bacterial LPS exposure. These observations were consistent with the profile of transcriptional responses that were dominated by modulation of immune response genes. Maggot therapy may therefore improve wound healing through the secondary effects of these gene changes in the wound cells.

Urate Oxidase produced by Lucilia sericata medical maggots is localized in Malpighian tubes and facilitates allantoin production

Lucilia sericata maggots are the only species currently approved for maggot debridement therapy (MDT), an alternative treatment for chronic and recalcitrant wounds. Maggots promote wound debridement, disinfection and healing by producing a complex mixture of proteins, peptides and low-molecular-weight compounds in their secretions and excretions, but the individual components are not well characterized at the molecular level. Here we investigated the purine catabolism pathway in L. sericata, focusing on the production of allantoin by Urate Oxidase (UO), which is thought to promote wound healing. We produced recombinant L. sericata UO in Escherichia coli, and characterized the properties of the pure enzyme in terms of the optimum pH (7-10) and temperature (20-25 °C), its stability, sensitivity to inhibition and ion dependency. We used quantitative RT-PCR and RNA in situ hybridization to monitor the expression of the UO gene, and we used a guinea pig anti-UO antibody to detect the native enzyme by western blot and by florescence immunohistochemistry in larval tissues. We found that L. sericata UO is exclusively present in the larval excretion organ (the Malpighian tubes) and is freely available in the cytoplasm rather than restricted to a specific subcellular compartment. Allantoin is a final product of L. sericata purine catabolism. It is produced by UO in the Malpighian tubes to remove uric acid from the hemolymph and is consequently excreted via the hindgut. Our findings confirm the hypothesis that both actively secreted molecules and excretion products contribute to the beneficial effects of MDT.

CARACTERIZAÇÃO BIOQUÍMICA DO PRODUTO DE EXCREÇÃO/SECREÇÃO DE LARVAS DE Cochliomyia hominivorax (DIPTERA: CALLIPHORIDAE)

Resumo A espécie Cochliomyia hominivorax, conhecida popularmente como mosca da bicheira, é um parasita obrigatório de animais de sangue quente e sua distribuição geográfica estende-se por toda a América do Sul, excetuando-se o Chile. O parasitismo por esta mosca provoca perdas econômicas significativas e tem grande importância no Brasil. São poucos os estudos com foco nos produtos de excreção e secreção desta espécie e este trabalho teve como objetivo estudar as enzimas presentes no produto de secreção e excreção (E/S) dos três estádios larvais de C. hominivorax. O perfil de proteínas foi obtido por eletroforese em gel de poliacrilamida e a atividade proteolítica foi analisada utilizando-se gelatina, azocaseína e Na-benzoil-arginina-nitroanilida (BAPNA) como substrato. Nos produtos de E/S dos três estádios, as proteínas foram detectadas com um peso molecular aparente que variou entre 116 e 20 kDa. No ensaio de azocaseína, em diferentes faixas de pH, a maior atividade proteolítica ocorreu em pH 7,5 para todos os estádios larvais. Os ensaios foram realizados usando-se estes mesmos substratos e as amostras foram tratadas com os inibidores Benzamidina, Pepstatin A, 4-(2-aminoetil)benzenosulfonil fluoreto hidrocloreto (AEBSF), N-α-tosil-L-lisina clorometil cetona (TLCK), N-α-tosil-L-fenilalanina clorometil cetona (TPCK), Ácido etilenodiamino tetra acético (EDTA), Leupeptina e Trans-epoxysuccinyl L-leucylamido-4-guanidino butano (E-64). As proteinases presentes nos produtos E/S de L1 são em sua maioria serina proteases do tipo tripsina e quimotripsina, enquanto que para os produtos E/S de L2 e L3 foi evidenciada a presença de serina proteases e aspartil proteases.

TIME management by medicinal larvae

Wound bed preparation (WBP) is an integral part of the care programme for chronic wounds. The acronym TIME is used in the context of WBP and describes four barriers to healing in chronic wounds; namely, dead Tissue, Infection and inflammation, Moisture imbalance and a non-migrating Edge. Larval debridement therapy (LDT) stems from observations that larvae of the blowfly Lucilia sericata clean wounds of debris. Subsequent clinical studies have proven debriding efficacy, which is likely to occur as a result of enzymatically active alimentary products released by the insect. The antimicrobial, anti-inflammatory and wound healing activities of LDT have also been investigated, predominantly in a pre-clinical context. This review summarises the findings of investigations into the molecular mechanisms of LDT and places these in context with the clinical concept of WBP and TIME. It is clear from these findings that biotherapy with L. sericata conforms with TIME, through the enzymatic removal of dead tissue and its associated biofilm, coupled with the secretion of defined antimicrobial peptides. This biotherapeutic impact on the wound serves to reduce inflammation, with an associated capacity for an indirect effect on moisture imbalance. Furthermore, larval serine proteinases have the capacity to alter fibroblast behaviour in a manner conducive to the formation of granulation tissue.

Traditional Therapies for Skin Wound Healing

Significance: The regeneration of healthy and functional skin remains a huge challenge due to its multilayer structure and the presence of different cell types within the extracellular matrix in an organized way. Despite recent advances in wound care products, traditional therapies based on natural origin compounds, such as plant extracts, honey, and larvae, are interesting alternatives. These therapies offer new possibilities for the treatment of skin diseases, enhancing the access to the healthcare, and allowing overcoming some limitations associated to the modern products and therapies, such as the high costs, the long manufacturing times, and the increase in the bacterial resistance. This article gives a general overview about the recent advances in traditional therapies for skin wound healing, focusing on the therapeutic activity, action mechanisms, and clinical trials of the most commonly used natural compounds. New insights in the combination of traditional products with modern treatments and future challenges in the field are also highlighted. Recent Advances: Natural compounds have been used in skin wound care for many years due to their therapeutic activities, including anti-inflammatory, antimicrobial, and cell-stimulating properties. The clinical efficacy of these compounds has been investigated through in vitro and in vivo trials using both animal models and humans. Besides the important progress regarding the development of novel extraction methods, purification procedures, quality control assessment, and treatment protocols, the exact mechanisms of action, side effects, and safety of these compounds need further research. Critical Issues: The repair of skin lesions is one of the most complex biological processes in humans, occurring throughout an orchestrated cascade of overlapping biochemical and cellular events. To stimulate the regeneration process and prevent the wound to fail the healing, traditional therapies and natural products have been used with promising results. Although these products are in general less expensive than the modern treatments, they can be sensitive to the geographic location and season, and exhibit batch-to-batch variation, which can lead to unexpected allergic reactions, side effects, and contradictory clinical results. Future Directions: The scientific evidence for the use of traditional therapies in wound healing indicates beneficial effects in the treatment of different lesions. However, specific challenges remain unsolved. To extend the efficacy and the usage of natural substances in wound care, multidisciplinary efforts are necessary to prove the safety of these products, investigate their side effects, and develop standard controlled trials. The development of good manufacturing practices and regulatory legislation also assume a pivotal role in order to improve the use of traditional therapies by the clinicians and to promote their integration into the national health system. Current trends move to the development of innovative wound care treatments, combining the use of traditional healing agents and modern products/practices, such as nanofibers containing silver nanoparticles, Aloe vera loaded into alginate hydrogels, propolis into dressing films, and hydrogel sheets containing honey.

Next Generation Sequencing Identifies Five Major Classes of Potentially Therapeutic Enzymes Secreted by Lucilia sericata Medical Maggots

Lucilia sericata larvae are used as an alternative treatment for recalcitrant and chronic wounds. Their excretions/secretions contain molecules that facilitate tissue debridement, disinfect, or accelerate wound healing and have therefore been recognized as a potential source of novel therapeutic compounds. Among the substances present in excretions/secretions various peptidase activities promoting the wound healing processes have been detected but the peptidases responsible for these activities remain mostly unidentified. To explore these enzymes we applied next generation sequencing to analyze the transcriptomes of different maggot tissues (salivary glands, gut, and crop) associated with the production of excretions/secretions and/or with digestion as well as the rest of the larval body. As a result we obtained more than 123.8 million paired-end reads, which were assembled de novo using Trinity and Oases assemblers, yielding 41,421 contigs with an N50 contig length of 2.22 kb and a total length of 67.79 Mb. BLASTp analysis against the MEROPS database identified 1729 contigs in 577 clusters encoding five peptidase classes (serine, cysteine, aspartic, threonine, and metallopeptidases), which were assigned to 26 clans, 48 families, and 185 peptidase species. The individual enzymes were differentially expressed among maggot tissues and included peptidase activities related to the therapeutic effects of maggot excretions/secretions.

A Jonah-like chymotrypsin from the therapeutic maggot Lucilia sericata plays a role in wound debridement and coagulation

Lucilia sericata larvae are used in maggot debridement therapy, a traditional wound healing approach that has recently been approved for the treatment of chronic wounds. Maggot excretion products (MEP) contain many different proteases that promote disinfection, debridement and the acceleration of wound healing, e.g. by activating the host contact phase/intrinsic pathway of coagulation. In order to characterise relevant procoagulant proteases, we analysed MEP and identified a chymotrypsin-like serine protease with similarities to Jonah proteases from Drosophila melanogaster and a chymotrypsin from Lucilia cuprina. A recombinant form of the L. sericata Jonah chymotrypsin was produced in Escherichia coli. The activated enzyme (Jonahm) had a pH optimum of 8.0 and a temperature optimum of 37 °C, based on the cleavage of the chromogenic peptide s-7388 and casein. Jonahm reduced the clotting time of human plasma even in the absence of the endogenous protease kallikrein, factor XI or factor XII and digested the extracellular matrix proteins fibronectin, laminin and collagen IV, suggesting a potential mechanism of wound debridement. Based on these characteristics, the novel L. sericata chymotrypsin-like serine protease appears to be an ideal candidate for the development of topical drugs for wound healing applications.

Maggot excretion products from the blowfly Lucilia sericata contain contact phase/intrinsic pathway-like proteases with procoagulant functions

For centuries, maggots have been used for the treatment of wounds by a variety of ancient cultures, as part of their traditional medicine. With increasing appearance of antimicrobial resistance and in association with diabetic ulcers, maggot therapy was revisited in the 1980s. Three mechanisms by which sterile maggots of the green bottle fly Lucilia sericata may improve healing of chronic wounds have been proposed: Biosurgical debridement, disinfecting properties, and stimulation of the wound healing process. However, the influence of maggot excretion products (MEP) on blood coagulation as part of the wound healing process has not been studied in detail. Here, we demonstrate that specific MEP-derived serine proteases from Lucilia sericata induce clotting of human plasma and whole blood, particularly by activating contact phase proteins factor XII and kininogen as well as factor IX, thereby providing kallikrein-bypassing and factor XIa-like activities, both in plasma and in isolated systems. In plasma samples deficient in contact phase proteins, MEP restored full clotting activity, whereas in plasma deficient in either factor VII, IX, X or II no effect was seen. The observed procoagulant/intrinsic pathway-like activity was mediated by (chymo-) trypsin-like proteases in total MEP, which were significantly blocked by C1-esterase inhibitor or other contact phase-specific protease inhibitors. No significant influence of MEP on platelet activation or fibrinolysis was noted. Together, MEP provides contact phase bypassing procoagulant activity and thereby induces blood clotting in the context of wound healing. Further characterisation of the active serine protease(s) may offer new perspectives for biosurgical treatment of chronic wounds.

The effects of Sarconesiopsis magellanica larvae (Diptera: Calliphoridae) excretions and secretions on fibroblasts

Sarconesiopsis magellanica is a necrophagous blowfly which is relevant in both forensic and medical sciences. Previous studies regarding this species have led to understanding life-cycle, population and reproduction parameters, as well as identifying and characterising proteolytic enzymes derived from larval excretions and secretions (ES). As other studies have shown that ES proteolytic activity plays a significant role in wound healing and fibroblasts play a relevant role in granulation tissue formation during such healing, the present study was aimed at analysing the biological effect of S. magellanica larval ES on fibroblasts. ES were obtained from third-instar larvae and added to fibroblast cells at three concentrations (10, 5 and 1 μg/mL) to evaluate their behaviour. MTT assays were used for analysing cell proliferation and viability, whilst cell adhesion was measured by optical density with 10% SDS. Fibroblast migration and morphology was recorded by microscopic observation. ES did not affect fibroblast viability and induced an increase in cell proliferation; cell adhesion became reduced, whilst cell migration through extracellular matrix increased. ES also induced a decreased cell surface and morphological alterations. Changes in all the above-mentioned parameters were reduced when ES were incubated at 60 °C, probably due to protease denaturation. These results suggested that the proteases contained in S. magellanica larval ES contributed towards granulation tissue formation, increased cell migration and promoted cell proliferation. All these data support carrying out further experiments aimed at validating S. magellanica usefulness in larval therapy.

Maggot debridement therapy: a systematic review

Maggot debridement therapy is used extensively in the UK in both community and hospital situations, but remains a potentially under-used modality in many wound care markets. It promotes wound healing by performing three key processes: debridement, disinfection and growth-promoting activity. It can be used for the debridement of non-healing necrotic skin and soft tissue wounds, including pressure ulcers, venous stasis ulcers, neuropathic foot ulcers and non-healing traumatic of post-surgical wounds. With the increase in chronic diabetic foot wounds, maggot debridement therapy is a promising tool for health professionals dealing with difficult wounds. This article presents an overview of the research evidence surrounding maggot debridement therapy that serves as a guide to health professionals who may be users of this form of treatment now and in the future.

A novel serine protease secreted by medicinal maggots enhances plasminogen activator-induced fibrinolysis

Maggots of the blowfly Lucilia sericata are used for the treatment of chronic wounds. As haemostatic processes play an important role in wound healing, this study focused on the effects of maggot secretions on coagulation and fibrinolysis. The results showed that maggot secretions enhance plasminogen activator-induced formation of plasmin and fibrinolysis in a dose- and time-dependent manner. By contrast, coagulation was not affected by secretions. Biochemical studies indicated that a novel serine protease within secretions, designated Sericase, cleaved plasminogen to several fragments. Recombinant Sericase degraded plasminogen leading amongst others to the formation of the mini-plasminogen like fragment Val454-plasminogen. In addition, the presence of a non-proteolytic cofactor in secretions was discovered, which plays a role in the enhancement of plasminogen activator-induced fibrinolysis by Sericase. We conclude from our in vitro studies that the novel serine protease Sericase, with the aid of a non-proteolytic cofactor, enhances plasminogen activator-induced fibrinolysis.

Lucifensins, the Insect Defensins of Biomedical Importance: The Story behind Maggot Therapy

Defensins are the most widespread antimicrobial peptides characterised in insects. These cyclic peptides, 4–6 kDa in size, are folded into α-helical/β-sheet mixed structures and have a common conserved motif of three intramolecular disulfide bridges with a Cys1-Cys4, Cys2-Cys5 and Cys3-Cys6 connectivity. They have the ability to kill especially Gram-positive bacteria and some fungi, but Gram-negative bacteria are more resistant against them. Among them are the medicinally important compounds lucifensin and lucifensin II, which have recently been identified in the medicinal larvae of the blowflies Lucilia sericata and Lucilia cuprina, respectively. These defensins contribute to wound healing during a procedure known as maggot debridement therapy (MDT) which is routinely used at hospitals worldwide. Here we discuss the decades-long story of the effort to isolate and characterise these two defensins from the bodies of medicinal larvae or from their secretions/excretions. Furthermore, our previous studies showed that the free-range larvae of L. sericata acutely eliminated most of the Gram-positive strains of bacteria and some Gram-negative strains in patients with infected diabetic foot ulcers, but MDT was ineffective during the healing of wounds infected with Pseudomonas sp. and Acinetobacter sp. The bactericidal role of lucifensins secreted into the infected wound by larvae during MDT and its ability to enhance host immunity by functioning as immunomodulator is also discussed.

Sterilization of Chrysomya putoria (Insecta: Diptera: Calliphoridae) eggs for use in biotherapy

Large-scale, quality-controlled laboratory production of fly larvae is needed for biotherapy. The objective of this study was to assess the action of glutaraldehyde on the sterilization of Chrysomya putoria eggs by applying pharmaceutical sterility tests. Egg masses with 0.600 g were divided into three parts of 0.200 g, the eggs were separated using sterile distilled water, and the suspensions obtained were mixed with activated 2% glutaraldehyde solution. After 15-min contact, the suspensions were filtered through Whatman filter paper, and the glutaraldehyde residue obtained in the filtrate was neutralized by rinsing with Tryptone Soy Broth. The treated eggs were placed aseptically on Petri dishes containing gauze moistened with sterile saline solution. About 10% of the sterilized mass was transferred to test tubes containing Tryptone Soy Broth and Fluid Thioglycollate Broth. The tubes were incubated, respectively, at 22.5 and 35.0°C for 14 d to verify egg mass sterility. The plates containing the rest of the eggs (90%) were sealed with plastic film and kept in a climatized chamber at 30°C/d, 28°C per night, 60 ± 10% relative humidity, and under a 12-h light period to assess insect viability and survival. Each experiment was carried out in triplicate using a biological class II safety cabinet. No change in color or turgidity was observed with the agent tested, proving the sterility of the product and that there was no trace of contamination. Forty larvae (in three replications) in the periods of 12, 24, and 48 h after sterilization, when transferred to diet, produced larvae, pupae, and total viability similar to the control (larvae without sterilization). However, for the 72-h treatment, larvae and total viability were significantly lower than for the other treatments. There was no significant difference for the pupal stage. The product tested was shown to be efficacious for use as a sterilizer of C. putoria eggs for all the parameters assessed.

In vitro antibacterial activity and physicochemical properties of a crude methanol extract of the larvae of the blow fly Lucilia cuprina

The emergence of multidrug-resistant bacterial strains has prompted the reintroduction of maggot therapy in the treatment of chronic, infected wounds. Many previous studies have demonstrated the potent antibacterial activity of larval excretions/secretions of the blowfly Lucilia sericata (Meigen) (Diptera:Calliphoridae) against bacteria. However, the antibacterial activity of its sibling species, Lucilia cuprina (Wiedemann) (Diptera:Calliphoridae) against a wide range of pathogenic bacteria has never been determined. The aim of this study was to develop a new procedure to produce whole body extract of larvae of L. cuprina via methanol extraction as well as to demonstrate the in vitro antibacterial activity of this extract against seven selected wound pathogens (Staphylococcus aureus, methicillin-resistant S. aureus, S. epidermidis, Streptococcus pyogenes, Klebsiella pneumoniae, Pseudomonas aeruginosa and Escherichia coli). The turbidimetric assay demonstrated that L. cuprina larval extract was significantly potent against all bacteria tested (P < 0.001). Additionally, colony-forming unit (CFU), agar well diffusion and minimum inhibitory concentration assays have confirmed the apparent potency of larval extract against P. aeruginosa. The reconstituted larval extract was highly robust and thermally stable. These observations substantiated the feasibility of the methanol extraction method in the production of larval extract.

Proteolytic activity regarding Sarconesiopsis magellanica (Diptera: Calliphoridae) larval excretions and secretions

Sarconesiopsis magellanica (Diptera: Calliphoridae) is a medically important necrophagous fly which is used for establishing the post-mortem interval. Diptera maggots release proteolytic enzymes contained in larval excretion and secretion (ES) products playing a key role in digestion. Special interest in proteolytic enzymes has also been aroused regarding understanding their role in wound healing since they degrade necrotic tissue during larval therapy. This study was thus aimed at identifying and characterising S. magellanica proteolytic enzyme ES products for the first time. These products were obtained from first-, second- and third-instar larvae taken from a previously-established colony. ES proteins were separated by SDS-PAGE and their proteolytic activity was characterised by zymograms and inhibition assays involving BAPNA (Nα-benzoyl-dl-Arg-p-nitroanilide) and SAPNA substrates, using synthetic inhibitors. The protein profile ranged from ∼69kDa to ∼23kDa; several of them coincided with the Lucilia sericata ES protein profile. Serine-protease hydrolysis activity (measured by zymogram) was confirmed when a ∼25kDa band disappeared upon ES incubation with PMSF inhibitor at pH 7.8. Analysis of larval ES proteolytic activity on BAPNA and SAPNA substrates (determined by using TLCK and TPCK specific inhibitors) suggested a greater amount of trypsin-like protease. These results support the need for further experiments aimed at validating S. magellanica use in larval therapy.

Complement activation and inhibition in wound healing

Complement activation is needed to restore tissue injury; however, inappropriate activation of complement, as seen in chronic wounds can cause cell death and enhance inflammation, thus contributing to further injury and impaired wound healing. Therefore, attenuation of complement activation by specific inhibitors is considered as an innovative wound care strategy. Currently, the effects of several complement inhibitors, for example, the C3 inhibitor compstatin and several C1 and C5 inhibitors, are under investigation in patients with complement-mediated diseases. Although (pre)clinical research into the effects of these complement inhibitors on wound healing is limited, available data indicate that reduction of complement activation can improve wound healing. Moreover, medicine may take advantage of safe and effective agents that are produced by various microorganisms, symbionts, for example, medicinal maggots, and plants to attenuate complement activation. To conclude, for the development of new wound care strategies, (pre)clinical studies into the roles of complement and the effects of application of complement inhibitors in wound healing are required.

Maggot excretions affect the human complement system

The complement system plays an important role in the activation of the inflammatory response to injury, although inappropriate complement activation (CA) can lead to severe tissue damage. Maggot therapy is successfully used to treat infected wounds. In this study, we hypothesized that maggot excretions/secretions influence CA in order to modulate the host's inflammatory response. Therefore, the effect of maggot excretions on CA was investigated in preoperatively and postoperatively obtained sera from patients. Our results show that maggot excretions reduce CA in healthy and postoperatively immune-activated human sera up to 99.9%, via all pathways. Maggot excretions do not specifically initiate or inhibit CA, but break down complement proteins C3 and C4 in a cation-independent manner and this effect proves to be temperature tolerant. This study indicates a CA-reducing substrate that is already successfully used in clinical practice and may explain part of the improved wound healing caused by maggot therapy. Furthermore, the complement activation-reducing substance present in maggot excretions could provide a novel treatment modality for several diseases, resulting from an (over)active complement system.

Wound debridement potential of glycosidases of the wound-healing maggot, Lucilia sericata

The wound-healing maggot, Lucilia sericata Meigen (Diptera: Calliphoridae), degrades extracellular matrix components by releasing enzymes. The purpose of this study was to investigate the glycosylation profiles of wound slough/eschar from chronic venous leg ulcers and the complementary presence of glycosidase activities in first-instar excretions/secretions (ES1) and to define their specificities. The predominant carbohydrate moieties present in wound slough/eschar were determined by probing one-dimensional Western blots with conjugated lectins of known specificities. The presence of specific glycosidase activities in ES1 was determined using chromogenic and fluorogenic substrates. The removal of carbohydrate moieties from slough/eschar proteins by glycosidases in ES1 was determined by two-dimensional electrophoresis and Emerald 300 glycoprotein staining. α-D-glucosyl, α-D-mannosyl and N-acetylglucosamine residues were detected on slough/eschar-derived proteins. Furthermore, it was demonstrated that the treatment of slough/eschar with ES1 significantly reduced uptake of the carbohydrate-specific stain. Subsequently, α-D-glucosidase, α-D-mannosidase and N-acetylglucosaminidase activities were identified in ES1. Specific chromogenic and fluorogenic substrates and gel filtration chromatography showed that these activities result from distinct enzymes. These activities were mirrored in the removal of α-D-glucosyl, α-D-mannosyl and N-acetylglucosamine residues from proteins of slough/eschar from maggot-treated wounds. These data suggest that maggot glycosidases remove sugars from slough/eschar proteins. This may contribute to debridement, which is ultimately accomplished by a suite of biochemically distinct enzymes present in ES1.

[Poorly healing periorbital wounds. Therapeutic use of maggots]

The treatment of poorly healing wounds, although not a typical problem in the periorbital area, has been enriched by the option of biosurgery, the therapeutic application of larvae of the blow fly (Lucilia sericata).

Insect natural products and processes: new treatments for human disease

In this overview, some of the more significant recent developments in bioengineering natural products from insects with use or potential use in modern medicine are described, as well as in utilisation of insects as models for studying essential mammalian processes such as immune responses to pathogens. To date, insects have been relatively neglected as sources of modern drugs although they have provided valuable natural products, including honey and silk, for at least 4-7000 years, and have featured in folklore medicine for thousands of years. Particular examples of Insect Folk Medicines will briefly be described which have subsequently led through the application of molecular and bioengineering techniques to the development of bioactive compounds with great potential as pharmaceuticals in modern medicine. Insect products reviewed have been derived from honey, venom, silk, cantharidin, whole insect extracts, maggots, and blood-sucking arthropods. Drug activities detected include powerful antimicrobials against antibiotic-resistant bacteria and HIV, as well as anti-cancer, anti-angiogenesis and anti-coagulant factors and wound healing agents. Finally, the many problems in developing these insect products as human therapeutic drugs are considered and the possible solutions emerging to these problems are described.

Maggot chymotrypsin I from Lucilia sericata is resistant to endogenous wound protease inhibitors

BACKGROUND

A chymotrypsin found in the secretions of Lucilia sericata and manufactured as a recombinant enzyme degrades chronic wound eschar ex vivo.

OBJECTIVES

To characterize the inhibition profile of the L. sericata recombinant chymotrypsin I.

METHODS

Activity of recombinant chymotrypsin I and its sensitivity to endogenous inhibitors were determined enzymatically using the fluorogenic substrate succinyl-alanyl-alanyl-prolyl-phenylalanyl-aminomethyl coumarin.

RESULTS

We report the presence of high concentrations of two endogenous inhibitors, α1-antichymotrypsin and α1-antitrypsin, in wound eschar and a trace of a third, α2-macroglobulin, with the potential to inhibit this debridement process. However, the addition of a soluble and inhibitor-containing extract of chronic wound eschar to chymotrypsin I did not affect activity of the enzyme, neither did the addition of purified native α1-antichymotrypsin or α1-antitrypsin, although chymotrypsin I was inhibited by α2-macroglobulin. Conversely, the mammalian equivalent, α-chymotrypsin, was inhibited by the purified native α1-antichymotrypsin, α1-antitrypsin and α2-macroglobulin and by the soluble extract of wound eschar.

CONCLUSIONS

The data suggest that the maggot-derived chymotrypsin I is biochemically distinct from human α-chymotrypsin and the lack of inhibition by wound eschar suggests a means by which chymotrypsin I activity survives within the wound to contribute towards debridement during maggot biotherapy.

Degradation of eschar from venous leg ulcers using a recombinant chymotrypsin from Lucilia sericata

BACKGROUND

Larvae of the greenbottle Lucilia sericata are used to debride nonhealing wounds and stimulate the production of fresh granulation tissue. Previous publications have shown that secretions from L. sericata contain a number of proteolytic activities including a chymotrypsin that degrades a number of extracellular matrix components such as fibronectin, laminin and collagen.

OBJECTIVES

To produce a recombinant L. sericata chymotrypsin (chymotrypsin I) and determine its effects on the degradation of patient wound eschar.

METHODS

An active recombinant chymotrypsin I from L. sericata was cloned and expressed in Sf9 cells and its subsequent effects ex vivo on eschar from venous leg ulcers were determined by two-dimensional electrophoresis.

RESULTS

The recombinant enzyme had the attributes of a chymotrypsin, possessing sequence homology with other chymotrypsins and demonstrating attributes of the native enzyme including cleavage of the chymotrypsin substrate succinyl-alanyl-alanyl-prolyl-phenylalanyl-7-amino-4-methyl coumarin, inhibition by phenylmethylsulphonyl fluoride and lack of inhibition by amidinophenylmethylsulphonyl fluoride. Importantly, the recombinant chymotrypsin cleaved the majority of proteins from slough/eschar from venous leg ulcers in a superior manner to chymotrypsins from human and bovine sources.

CONCLUSIONS

The ex vivo degradation of eschar from venous leg ulcers indicates the potential value of recombinant chymotrypsin I as a novel, stand-alone debridement agent.

Clinical research on the bio-debridement effect of maggot therapy for treatment of chronically infected lesions

OBJECTIVE

To evaluate the bio-debridement effect of maggot therapy for treating chronically infected lesions.

METHODS

A retrospective study was conducted of 25 patients with diabetic foot ulcers and 18 patients with pressure ulcers after spinal cord injury treated by maggot therapy or traditional dressing. Changes in the lesions were observed and bacterial cultures tested.

RESULTS

All ulcers healed completely. The times taken to achieve bacterial negativity, granulation and healing of lesions were all significantly shorter in the maggot therapy group than in the control group, both for diabetic foot ulcers (P < 0.05) and pressure ulcers (P < 0.05).

CONCLUSION

Maggot therapy is a safe and effective method for treating chronically infected lesions.

Maggot secretions suppress pro-inflammatory responses of human monocytes through elevation of cyclic AMP

AIMS/HYPOTHESIS

Maggots of the blowfly Lucilia sericata are used for the treatment of chronic wounds. As monocytes may contribute to the excessive inflammatory responses in such wounds, this study focussed on the effects of maggot secretions on the pro-inflammatory activities of these cells.

METHODS

Freshly isolated monocytes were incubated with a range of secretions for 1 h and then stimulated with lipopolysaccharides (range 0-100 ng/ml) or lipoteichoic acid (range 0-5 microg/ml) for 18 h. The expression of cell surface molecules, cytokine and chemokine levels in culture supernatants, cell viability, chemotaxis, and phagocytosis and killing of Staphylococcus aureus were measured.

RESULTS

Maggot secretions dose-dependently inhibited production of the pro-inflammatory cytokines TNF-alpha, IL-12p40 and macrophage migration inhibitory factor by lipopolysaccharides- and lipoteichoic acid-stimulated monocytes, while enhancing production of the anti-inflammatory cytokine IL-10. Expression of cell surface receptors involved in pathogen recognition remained unaffected by secretions. In addition, maggot secretions altered the chemokine profile of monocytes by downregulating macrophage inflammatory protein-1beta and upregulating monocyte chemoattractant protein-1 and IL-8. Nevertheless, chemotactic responses of monocytes were inhibited by secretions. Furthermore, maggot secretions did not affect phagocytosis and intracellular killing of S. aureus by human monocytes. Finally, secretions induced a transient rise in the intracellular cyclic AMP concentration in monocytes and Rp-cyclic AMPS inhibited the effects of secretions.

CONCLUSIONS/INTERPRETATION

Maggot secretions inhibit the pro-inflammatory responses of human monocytes through a cyclic AMP-dependent mechanism. Regulation of the inflammatory processes by maggots contributes to their beneficial effects on chronic wounds.

Larval therapy for leg ulcers (VenUS II): randomised controlled trial

OBJECTIVE

To compare the clinical effectiveness of larval therapy with a standard debridement technique (hydrogel) for sloughy or necrotic leg ulcers.

DESIGN

Pragmatic, three armed randomised controlled trial.

SETTING

Community nurse led services, hospital wards, and hospital outpatient leg ulcer clinics in urban and rural settings, United Kingdom.

PARTICIPANTS

267 patients with at least one venous or mixed venous and arterial ulcer with at least 25% coverage of slough or necrotic tissue, and an ankle brachial pressure index of 0.6 or more.

INTERVENTIONS

Loose larvae, bagged larvae, and hydrogel.

MAIN OUTCOME MEASURES

The primary outcome was time to healing of the largest eligible ulcer. Secondary outcomes were time to debridement, health related quality of life (SF-12), bacterial load, presence of meticillin resistant Staphylococcus aureus, adverse events, and ulcer related pain (visual analogue scale, from 0 mm for no pain to 150 mm for worst pain imaginable).

RESULTS

Time to healing was not significantly different between the loose or bagged larvae group and the hydrogel group (hazard ratio for healing using larvae v hydrogel 1.13, 95% confidence interval 0.76 to 1.68; P=0.54). Larval therapy significantly reduced the time to debridement (2.31, 1.65 to 3.2; P<0.001). Health related quality of life and change in bacterial load over time were not significantly different between the groups. 6.7% of participants had MRSA at baseline. No difference was found between larval therapy and hydrogel in their ability to eradicate MRSA by the end of the debridement phase (75% (9/12) v 50% (3/6); P=0.34), although this comparison was underpowered. Mean ulcer related pain scores were higher in either larvae group compared with hydrogel (mean difference in pain score: loose larvae v hydrogel 46.74 (95% confidence interval 32.44 to 61.04), P<0.001; bagged larvae v hydrogel 38.58 (23.46 to 53.70), P<0.001).

CONCLUSIONS

Larval therapy did not improve the rate of healing of sloughy or necrotic leg ulcers or reduce bacterial load compared with hydrogel but did significantly reduce the time to debridement and increase ulcer pain.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN55114812 and National Research Register N0484123692.

Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century

In the 21st century, eighty years after William Baer presented his groundbreaking work treating bone and soft tissue infections with live maggots, thousands of therapists around the globe have rediscovered the benefits of maggot therapy. The renaissance in maggot therapy is due in large part to recent technological advancements that have solved or minimized many of the treatment's earlier drawbacks: the need for reliable access to this perishable medical device, simplified application, and low-cost production. Modern dressing materials have simplified the procedure and minimized the risk of escaping maggots. The establishment of dozens of laboratories throughout the world, along with access to overnight courier services in many regions, has made medicinal maggots readily available to millions of people in need. Studies show that fears of patient nonacceptance are unfounded. The medical literature is rapidly growing with scientific evidence demonstrating the efficacy and safety of maggot therapy for a variety of problematic wounds. This article examines how these and other technologies are optimizing the study and application of maggot therapy for wound care.