Maggot Therapy for Problematic Wounds: Uncommon and Off-label Applications

Not all maggots are created equal; not all maggots are therapeutic

Maggots in a wound ("myiasis") cannot be considered maggot therapy (therapeutic myiasis) unless, at a minimum, the species is known to be safe and effective, and the maggots have been properly disinfected. Documenting treatment details is critical and allows us to determine the cause of problems, if they arise.

Combined application of moist exposed burn ointment and maggot therapy in wound healing

Objective:

Hard-to-heal wounds are a global health challenge, and effective treatments are still lacking. Moist exposed burn ointment (MEBO) and maggots are traditional treatments for promoting wound healing. This study was a preliminary exploration of combined maggot therapy and MEBO in the treatment of hard-to-heal wounds.

Method:

A coexistence experiment was conducted to determine the survival rates of maggots in MEBO. The maggots were placed in two different existence conditions: one set in MEBO (MEBO group), and another set as the control group (no MEBO) to compare survival rates. Case reports describe the use of the combined application of MEBO and maggots in the treatment of patients with hard-to-heal wounds.

Results:

The coexistence experiment indicated that maggots in the MEBO group had a higher survival rate. From the therapeutic effect of the clinical cases (n=7), the combined application was safe and effective, with all the reported wounds eventually healing.

Conclusion:

Based on the findings of this study, we believe the combined application of MEBO and maggots is a promising way of promoting wound healing. Further studies and clinical trials are needed to elucidate the mechanism of the combined application in promoting wound healing and to more persuasively clarify the therapeutic effect.

Sterilization of Lucilia sericata (Diptera: Calliphoridae) Eggs for Maggot Debridement Therapy

Maggot debridement therapy (MDT) is a therapy with the medical use of sterile fly larvae of certain species, particularly those within the Calliphoridae family including green bottle fly, Lucilia sericata (Meigan, Diptera: Calliphoridae), for treating chronically infected wounds and ulcers. Lucilia sericata flies were maintained under insectary conditions, and the eggs were sterilized using three treatments: hydrogen peroxide solutions, used as a hand disinfectant (Treatment 1-T1), hydrogen peroxide, surface disinfectant (Treatment 2-T2), and SaniHigene (Treatment 3-T3) and the control (without treatment). All three treatment caused the complete sterilization of eggs, and no bacterial colonies were found on the blood agar culture. The egg hatching rate after 72 h was much higher than after 24 h. Egg mortality in hydrogen peroxide solutions, T1 and T2, was 3-4% and less than in solution T3 (13%). Owing to less mortality and more sterility of the eggs, the aforementioned solutions are suggested to be appropriate for sterility in maggot therapy.

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.

Topical odour management in burn patients

Preventing microbial colonization or infections that cause offensive smells may lead to odor reduction. As both anaerobic and aerobic bacteria cause the release of malodor from wounds, the most direct way of avoiding or eliminating wound odor is to prevent or eradicate the responsible infection through the debridement of necrotic tissues. However, some burn patients with malodorous wounds are unable to undergo debridement due to systemic conditions, especially in the acute stage. Moreover, the optimal drug doses and dressings to ensure the efficacy and cost-effectiveness of odorous burn wound management is unclear. The purpose of this commentary is to outline the odor management options available for burn patients, focusing on topical strategies. Numerous potential therapies for treating odorous wounds after burn injuries are suggested.

Clinical study of Maggot therapy for Fournier's gangrene

Fournier's Gangrene is a fulminating necrotizing fasciitis of the perineum and genitalia. Standard treatment involves immediate excision of all necrotic tissue, aggressive antibiotic coverage, and supportive medical care. Still, the infection is commonly fatal or disfiguring. Wound treatment with disinfected blowfly larvae (maggot debridement therapy or MDT) has been shown to be highly effective, with multiple studies demonstrating effective debridement, disinfection, and promotion of granulation tissue. MDT also has been associated with preservation of viable tissue and minimised blood loss. This report describes a prospective clinical study of MDT for Fournier's gangrene aimed to test the hypothesis that early use of maggots could decrease the number of surgical treatments required to treat Fournier's gangrene. Subjects were provided with one initial surgical excision, followed by debridement using only medical grade Lucilia sericata larvae. Only two subjects were enrolled, both diabetic men. Intensive care and culture-directed antimicrobial coverage were administered as usual. Maggot debridement was associated with the disappearance of necrotic tissue, control of infection and granulation tissue growth. In both subjects, wounds healed without requiring further surgical resection or anatomical reconstruction. Maggot therapy decreased the number of surgical procedures that otherwise would have been necessary, and led to favourable outcomes.

Advantages of Maggot Debridement Therapy for Chronic Wounds: A Bibliographic Review

GENERAL PURPOSE

To present an overview of the advantages of maggot debridement therapy as a treatment for chronic wounds through the review of several larval properties.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will be able to:1. Summarize the use, process, and precautions for maggot debridement to treat chronic wounds.2. Synthesize the results of the bibliographic review of the use of maggot debridement to treat chronic wounds.

ABSTRACT

Maggot debridement therapy (MDT) is effective for ulcer debridement, achieving it in less time than other therapies. It offers a benefit to healing. However, it is unclear whether maggots reduce treatment time and there is considerable controversy around the treatment's potential antimicrobial action and cost-effectiveness. Nevertheless, it can be effective in preventing amputations and reducing the need for systemic antibiotics. This bibliographic review assesses the advantages of MDT as a treatment for chronic wounds through the review of several larval properties. The review was carried out by consulting biomedical databases including CINAHL, MEDLINE (PubMed), and Scopus, and concludes that MDT is an effective debridement and potential technique to facilitate healing. However, more data is needed on the wound type application frequency and the efficacy of treatment.

Flying maggots: a smart logistic solution to an enduring medical challenge

Purpose

Whilst there is a growing body of research which discusses the use of remotely piloted aircraft systems (RPAS) (otherwise known as “drones”) to transport medical supplies, almost all reported cases employ short range aircraft. The purpose of this paper is to consider the advantages and challenges inherent in the use of long endurance remotely piloted aircraft systems (LE-RPAS) aircraft to support the provision of medical supplies to remote locations – specifically “medical maggots” used in maggot debridement therapy (MDT) wound care.

Design/methodology/approach

After introducing both MDT and the LE-RPAS technology, the paper first reports on the outcomes of a case study involving 11 semi-structured interviews with individuals who either have experience and expertise in the use of LE-RPAS or in the provision of healthcare to remote communities in Western Australia. The insights gained from this case study are then synthesised to assess the feasibility of LE-RPAS assisted delivery of medical maggots to those living in such geographically challenging locations.

Findings

No insuperable challenges to the concept of using LE-RPAS to transport medical maggots were uncovered during this research – rather, those who contributed to the investigations from across the spectrum from operators to users, were highly supportive of the overall concept.

Practical implications

The paper offers an assessment of the feasibility of the use of LE-RPAS to transport medical maggots. In doing so, it highlights a number of infrastructure and organisational challenges that would need to be overcome to operationalise this concept. Whilst the particular context of the paper relates to the provision of medical support to a remote location of a developed country, the core benefits and challenges that are exposed relate equally to the use of LE-RPAS in a post-disaster response. To this end, the paper offers a high-level route map to support the implementation of the concept.

Social implications

The paper proposes a novel approach to the efficient and effective provision of medical care to remote Australian communities which, in particular, reduces the need to travel significant distances to obtain treatment. In doing so, it emphasises the importance in gaining acceptance of both the use of MDT and also the operation of RPAS noting that these have previously been employed in a military, as distinct from humanitarian, context.

Originality/value

The paper demonstrates how the use of LE-RPAS to support remote communities offers the potential to deliver healthcare at reduced cost compared to conventional approaches. The paper also underlines the potential benefits of the use of MDT to address the growing wound burdens in remote communities. Finally, the paper expands on the existing discussion of the use of RPAS to include its capability to act as the delivery mechanism for medical maggots.

Evaluating Sarconesiopsis magellanica blowfly-derived larval therapy and comparing it to Lucilia sericata-derived therapy in an animal model

Larval therapy is used as alternative treatment for hard-to-heal chronic and infected wounds. Lucilia sericata is the most used blowfly species. However, it has been shown recently that Sarconesiopsis magellanica larval excretions and secretions have potent antibacterial activity; this blowfly belongs to the Calliphoridae family. The present work has dealt with evaluating larval therapy using S. magellanica on wounds induced in diabetic rabbits and its action was compared to the effect induced by L. sericata. Twelve New Zealand White rabbits (Oryctolagus cuniculus) were used; they were divided into 4 groups, the first two being treated with larval therapy derived from both aforementioned necrophagous blowflies, an antibiotic was used in the third and the fourth was used as control. All the animals were wounded on the back and infected with Pseudomonas aeruginosa and Staphylococcus aureus. Samples of the secretion from each animal's infected wound were taken and sown on blood agar. The colony forming units were then counted. The PUSH scale was used for the macroscopic evaluation of the wounds. Bacterial control was encountered 48 h post-treatment in the treatments involving larval therapy and to a lesser extent with the antibiotic. Likewise, wound debridement was quicker and more efficient with larval therapy compared to the antibiotic group; however, wound closing time was 23 days in all treatments. The group treated with S. magellanica larvae had relatively quicker evolution until the proliferation phase and the start of maturation, even though there were no significant differences between both blowfly species evaluated here regarding treatments by the end of the treatment period. The present study has validated the diabetic rabbit model for inducing chronic wounds regarding larval therapy and has likewise confirmed the effectiveness of S. magellanica-derived larval therapy as an alternative for curing and healing wounds.

Helminthes and insects: maladies or therapies

By definition, parasites cause harm to their hosts. But, considerable evidence from ancient traditional medicine has supported the theory of using parasites and their products in treating many diseases. Maggots have been used successfully to treat chronic, long-standing, infected wounds which failed to respond to conventional treatment by many beneficial effects on the wound including debridement, disinfection, and healing enhancement. Maggots are also applied in forensic medicine to estimate time between the death and discovery of a corpse and in entomotoxicology involving the potential use of insects as alternative samples for detecting drugs and toxins in death investigations. Leeches are segmented invertebrates, famous by their blood-feeding habits and used in phlebotomy to treat various ailments since ancient times. Leech therapy is experiencing resurgence nowadays in health care principally in plastic and reconstructive surgery. Earthworms provide a source of medicinally useful products with potential antimicrobial, antiviral, and anticancer properties. Lumbrokinases are a group of fibrinolytic enzymes isolated and purified from earthworms capable of degrading plasminogen-rich and plasminogen-free fibrin and so can be used to treat various conditions associated with thrombotic diseases. Helminth infection has been proved to have therapeutic effects in both animal and human clinical trials with promising evidence in treating many allergic diseases and can block the induction of or reduce the severity of some autoimmune disorders as Crohn's disease or ulcerative colitis. What is more, venomous arthropods such as scorpions, bees, wasps, spiders, ants, centipedes, snail, beetles, and caterpillars. The venoms and toxins from these arthropods provide a promising source of natural bioactive compounds which can be employed in the development of new drugs to treat diseases as cancer. The possibility of using these active molecules in biotechnological processes can make these venoms and toxins a valuable and promising source of natural bioactive compounds. The therapeutic use of helminthes and insects will be of great value in biomedicine and further studies on insect toxins will contribute extensively to the development of Biomedical Sciences.

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.

Mechanisms of maggot-induced wound healing: what do we know, and where do we go from here?

MEDICINAL MAGGOTS ARE BELIEVED TO HAVE THREE MAJOR MECHANISMS OF ACTION ON WOUNDS, BROUGHT ABOUT CHEMICALLY AND THROUGH PHYSICAL CONTACT: debridement (cleaning of debris), disinfection, and hastened wound healing. Until recently, most of the evidence for these claims was anecdotal; but the past 25 years have seen an increase in the use and study of maggot therapy. Controlled clinical studies are now available, along with laboratory investigations that examine the interaction of maggot and host on a cellular and molecular level. This review was undertaken to extract the salient data, make sense, where possible, of seemingly conflicting evidence, and reexamine our paradigm for maggot-induced wound healing. Clinical and laboratory data strongly support claims of effective and efficient debridement. Clinical evidence for hastened wound healing is meager, but laboratory studies and some small, replicated clinical studies strongly suggest that maggots do promote tissue growth and wound healing, though it is likely only during and shortly after the period when they are present on the wound. The best way to evaluate-and indeed realize-maggot-induced wound healing may be to use medicinal maggots as a "maintenance debridement" modality, applying them beyond the point of gross debridement.

Increasing the options for management of large and complex chronic wounds with a scalable, closed-system dressing for maggot therapy

As reconstructive specialists, burn surgeons are often involved in managing large wounds of various etiologies. Such wounds can pose a management challenge, especially if they are chronic or occur in the setting of critical illness or multiple medical comorbidities. Medical maggots are an effective, selective, and low-risk method for wound debridement. However, their use in large and geometrically complex wounds is limited by the lack of scalability in currently available dressings, which are appropriate for smaller wounds but become cumbersome and ineffective in larger ones. This report describes a novel dressing designed for application of maggot debridement therapy in large and complex wounds. The authors then discuss how use of this dressing may create new management strategies for such wounds by allowing maggots to mechanically debride big, infected wounds. They describe the construction of a maggot containment dressing based on modified components from a negative pressure wound therapy system and provide a case report highlighting its successful clinical use in a large contaminated chronic wound resulting from Fournier's gangrene. In the case described, the novel dressing provided scalability, containment of maggots, control of secretions, and ease of use. The dressing created an environment suitable for maggot survival and allowed effective debridement of a heavily contaminated groin wound. The novel dressing described is shown to function appropriately, allowing controlled use of maggots for effective debridement of large, irregular wounds. Facilitating the use of maggots in such wounds may broaden the algorithm for their management.

Maggot therapy in wound management in modern era and a review of published literature

Maggot therapy is an old remedy, which is being looked into with renewed interest. The use of medicinal maggots was approved by Food and Drug Administration (FDA) as a medical device in 2004. Maggot therapy appears to be efficacious, well tolerated, and cost-effective. Because American Medical Association (AMA) and Centers for Medicare and Medicaid (CMS) released reimbursement coding guidelines with regards to maggot therapy, there is a potential for a wider use of maggot therapy in United States in the near future. Several mechanisms of action suggested for maggots in debriding wounds are discussed. While maggot therapy demonstrated effectiveness in necrotic wounds, not all wound types respond well to maggot therapy. Future large, randomized, well-designed studies would help better delineate the place of maggot therapy among other options for wound care, and determine whether maggot therapy should be initiated earlier in the course of treatment, or continued to be used as a last resort.

Maggot debridement therapy for postsurgical wound infection in scoliosis: a case series in five patients

STUDY DESIGN

Case series of 5 patients who developed resistant wound infection after scoliosis surgery.

OBJECTIVE

To present maggot debridement therapy (MDT) as an effective alternative to the conventional treatment in postsurgical infection in scoliosis.

SUMMARY OF BACKGROUND DATA

Numerous clinical reports have been published that describe outstanding effects of MDT, most notable on debridement, cleansing, disinfection, and healing of indolent wounds, many of which have previously failed to respond to conventional treatment. However, till date no reports have been found in the literature describing its use for the treatment of wound infection after scoliosis surgery, which has relatively longer and deeper wound.

METHODS

A total of 5 patients (2 females and 3 males) who developed wound infection after scoliosis correction surgery were included in this study. All were operated for neuromuscular scoliosis using posterior approach with pedicle screw fixation. All developed deep wound infection within 2 to 6 weeks of surgery, which was resistant to all kinds of conventional therapy. MDT applied in all using prepared commercially available maggot bags, and dressing was changed twice a week till wound shows signs of healing. After confirming negative culture, MDT was stopped and routine dressings or secondary closure was done. During the treatment, wound appearance, size, and development of healing were observed.

RESULTS

There were 1 patient with paralytic scoliosis and 4 with cerebral palsy. All wound healed completely within 5.2 ± 1.8 weeks of MDT or 8.8 ± 3.8 cycles of MDT. There was no recurrence on final follow-up of 21.6 ± 5.9 months. Wound size was also decreased from 24.2 ± 3.3 cm of pre-MDT to 11.8 ± 4.5 cm post-MDT showing 51.2% reduction in wound size. There was partial implant removal in 2 cases before MDT; however, no further implant extraction was needed in any case after MDT. Treatment was tolerated well by all patients without any obvious complications due to MDT.

CONCLUSION

We would propose to use MDT for the treatment of wound infection after scoliosis surgery as an effective alternative to conventional treatment. In this way, implant extraction could be avoided without losing any correction.

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.

Memory encoded throughout our bodies: molecular and cellular basis of tissue regeneration

When a sheep loses its tail, it cannot regenerate it in the manner of lizards. On the other hand, it is possible to clone mammals from somatic cells, showing that a complete developmental program is intact in a wounded sheep's tail the same way it is in a lizard. Thus, there is a requirement for more than only the presence of the entire genetic code in somatic cells for regenerative abilities. Thoughts like this have motivated us to assemble more than just a factographic synopsis on tissue regeneration. As a model, we review skin wound healing in chronological order, and when possible, we use that overview as a framework to point out possible mechanisms of how damaged tissues can restore their original structure. This article postulates the existence of tissue structural memory as a complex distributed homeostatic mechanism. We support such an idea by referring to an extremely fragmented literature base, trying to synthesize a broad picture of important principles of how tissues and organs may store information about their own structure for the purposes of regeneration. Selected developmental, surgical, and tissue engineering aspects are presented and discussed in the light of recent findings in the field. When a sheep loses its tail, it cannot regenerate it in the manner of lizards. On the other hand, it is possible to clone mammals from somatic cells, showing that a complete developmental program is intact in a wounded sheep's tail the same way it is in a lizard. Thus, there is a requirement for more than only the presence of the entire genetic code in somatic cells for regenerative abilities. Thoughts like this have motivated us to assemble more than just a factographic synopsis on tissue regeneration. As a model, we review skin wound healing in chronological order, and when possible, we use that overview as a framework to point out possible mechanisms of how damaged tissues can restore their original structure. This article postulates the existence of tissue structural memory as a complex distributed homeostatic mechanism. We support such an idea by referring to an extremely fragmented literature base, trying to synthesize a broad picture of important principles of how tissues and organs may store information about their own structure for the purposes of regeneration. Selected developmental, surgical, and tissue engineering aspects are presented and discussed in the light of recent findings in the field.