Pain Assessment in Patients Undergoing Maggot Debridement Therapy in the Process of Local Treatment of Chronic Wounds

(1) Background: Developing and implementing strategies for local wound care focused on improving the quality of life related to health status and reducing treatment costs for this patient group poses a challenge to contemporary healthcare systems. The utilization of Maggot Debridement Therapy (MDT) is one potential form of local therapy for preparing wounds for the healing process. The debridement of the wound bed with medical maggots is highly precise, and the defensins produced by the larvae eliminate bacteria and stimulate tissue regeneration. However, the presence of larvae in the wound may lead to the occurrence of pain symptoms. The aim of the study was to assess the intensity of pain during larval therapy in patients with chronic wounds treated in outpatient settings. (2) Patients and Methods: The study employed a diagnostic survey and estimation; the tool consisted of a research protocol comprising three parts (questionnaires). Inclusion criteria for the study were voluntary consent to participate (completion of the MDT acceptance questionnaire), chronic wounds of vascular etiology or pressure injuries, full-thickness skin or deep tissue damage, and pain intensity not exceeding four on the NRS (Numerical Rating Scale: 0-no pain, 10-the most severe pain) at the time of the study. Patient observation during the 3-day treatment was conducted by a wound care clinic nurse, assessing pain intensity once every 24 h during the larval dressing changes. (3) Results: Out of 348 individuals who qualified for MDT during the study period, 215 individuals participated in the study: 94 women (43.7%) and 121 men (56.3%). The age of the participants ranged from 28 to 97 years (mean 69.87 ± 12.95). Each participant experienced mild pain (2.26 ± 1.60 on the NRS) on the day of qualification for the study. An increase in pain intensity, according to subjective assessments, was reported by 29.3% of participants (n = 63). On the third day of MDT therapy, an increase in pain intensity was observed, reaching a mean value of 4.79 ± 2.12 (p < 0.0001). Participants with pressure injuries showed the lowest pain intensity, which increased in consecutive days for all types of wounds. Additionally, the increase in pain intensity in patients with vascular etiology wounds was greater compared to patients with pressure injuries (p < 0.001). (4) Conclusions: Local wound therapy with Lucilia sericata larvae increases pain intensity in the consecutive days of treatment. The wound area and the time since its occurrence may determine pain symptoms.

Larval Wound Therapy: Possibilities and Potential Limitations-A Literature Review

Patient-centered care (PCC) is recognized as a standard in healthcare for determining high quality. Honoring patients' values, experiences, needs, and preferences in devising, coordinating, and delivering care underscores the enhancement of the therapeutic rapport between patients and healthcare providers. Wound treatment involves a multi-stage process encompassing diagnostics and local wound dressing, which reduces the risk of infection through a coordinated interdisciplinary team. Within this team, nurses undertake specific professional functions and roles. The implementation of local therapy using innovative and scientifically substantiated methods may be hindered by a deficit of knowledge or inappropriate knowledge among staff and patients themselves. This study presents the challenges concerning the care of patients with chronic wounds treated using Lucilia sericata larvae, based on a review of the current scientific literature. A critical analysis of the literature spanning from 2002 to 2022 was conducted using the Medline, PubMed, Cochrane, and Termedia databases, employing keywords such as "maggot debridement therapy" in relation to acceptance and perception. As a result of the preliminary selection, 472 papers were identified, of which 12 publications were included in the development of this concept. The acquired data were organized and presented in the concluding section in the form of tables, accompanied by descriptions and references to individual studies. Negative psychological and somatic sensations were among the most prominent challenges among patients treated with Maggot Debridement Therapy (MDT). Pain related to peripheral ischemia or infection in this group of patients requires pain prophylaxis, including hyperalgesia and allodynia, in order to improve method tolerance. On the other hand, augmenting patients' understanding of MDT diminishes negative emotions, reinforces positive behaviors, and mitigates anxiety levels. MDT constitutes an effective and safe method. Its widespread use for chronic wounds requires substantial knowledge among healthcare professionals and patient education, along with that of their caregivers, to develop a positive attitude.

Current Therapeutic Modalities for the Management of Chronic Diabetic Wounds of the Foot

Impaired wound healing is common in patients with diabetes mellitus (DM). Different therapeutic modalities including wound debridement and dressing, transcutaneous electrical nerve stimulation (TENS), nanomedicine, shockwave therapy, hyperbaric (HBOT) and topical (TOT) oxygen therapy, and photobiomodulation (PBM) have been used in the management of chronic diabetic foot ulcers (DFUs). The selection of a suitable treatment method for DFUs depends on the hosts' physiological status including the intricacy and wound type. Effective wound care is considered a critical component of chronic diabetic wound management. This review discusses the causes of diabetic wounds and current therapeutic modalities for the management of DFUs, specifically wound debridement and dressing, TENS, nanomedicine, shockwave therapy, HBOT, TOT, and PBM.

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.

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.

What is the effect of larval therapy on the debridement of venous leg ulcers? A systematic review

AIM

To determine the impact of larval therapy on the debridement of venous leg ulcers, in comparison to other debridement methods or no debridement.

METHOD

Using systematic review methodology, published quantitative studies focusing on the effect of larval therapy on the debridement of venous leg ulcers were included. The search was conducted in January 2020 and updated in May 2021 using CINAHL, PubMed, Embase, and the Cochrane library, and returned 357 records, of which six studies met the inclusion criteria. Data were extracted using a predesigned extraction tool and all studies were quality appraised using the RevMan risk of bias assessment tool.

RESULTS

Larval therapy was found to debride at a faster rate than hydrogel (p = 0.011, p < 0.001, p = 0.0039), have a similar effect to sharp debridement (p = 0.12, p = 0.62), and was a resource-effective method of debridement (p < 0.05, p < 0.001, p < 0.001). When larval therapy in combination with compression therapy was compared to compression alone, larvae had a greater effect on debridement (p < 0.05), however, it did not improve overall wound healing rates (p = 0.54, p = 0.664, p = 0.02). Pain levels increased during larval therapy and reduced after treatment, when compared to other standard debridement techniques.

CONCLUSION

Larval therapy promotes rapid debridement of venous leg ulcers. However, further high quality randomised controlled trials, comparing larval therapy to other debridement methods for venous leg ulcers, incorporating the use of compression is required to determine the long term effects of larval therapy.

Efficacy of maggot debridement therapy on refractory leg ulcers of Behçet disease: an open-label study

BACKGROUND

Cutaneous ulcers of Behçet disease (BD) are rare but have high morbidity and resistance to conventional therapies. An important and essential aspect of ulcer management is debridement. Regarding maggot therapy (MT), excretions of the green bottle fly, Lucilia sericata, have been shown to have the ability to remove necrotic debris and promote healing.

AIM

To evaluate the efficacy of MT for cutaneous ulcers of BD.

METHODS

In this open-label trial, patients with BD with refractory leg ulcers suitable for MT were enrolled. Maggot application was performed until complete debridement was achieved, and all patients were followed up for 12 months afterwards to assess the total healing of ulcers.

RESULTS

In total, 24 patients with 32 ulcers were enrolled. Using MT, 91.6% of all ulcers were completely debrided. Mean time to debridement was 14.9 days and mean number of cycles required was 5.3. Mean ulcer size was decreased by 23% with treatment. Time to debridement was positively correlated with pretreatment ulcer size and ulcer duration (P = 0.01 and P < 0.01) but not with ulcer depth, comorbidities, smoking, age or sex (P > 0.05 for all). During follow-up, 79.1% of all ulcers healed completely. Mean time required for total healing was positively correlated with ulcer duration, pretreatment and post-treatment ulcer area, ulcer depth and mean time to total debridement (P < 0.03, P = 0.00, P = 0.04 and P < 0.01, respectively).

CONCLUSIONS

To our knowledge, the findings presented in this first and unique study may provide key answers about factors affecting success rate of MT in BD cutaneous ulcers.

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.

Phantom pain as an adverse effect after maggot (Lucilia sericata) debridement therapy: a case study

Maggot debridement therapy, also known as larval therapy, is a well known method of treatment for hard-to-heal and intractable wounds. This case study describes severe phantom pain as a rare adverse event of maggot therapy in patients after post-traumatic amputation of the leg. We also hypothesise and discuss the possibility that the phantom pain may be a result of maggot activity, not only through tissue debridement but also through nerve nourishment and nerve regeneration.

Use of maggot debridement therapy in hospitalised patients in Germany

Exact data regarding the clinical role of maggot debridement therapy (MDT) for wound care in a specific country are not available. Thus, we analysed the use of MDT in hospitalised patients in Germany. Detailed lists of all hospitalised cases treated with MDT in Germany for the years 2011 to 2016 were provided by the Federal Statistical Office as well as the lists of the 15 most frequent principal and additional diagnoses, respectively, and the 10 most frequent procedures documented with MDT in 2016. Within the 6-year time period of the study, the number of cases treated with MDT increased by 11% from 4513 in 2011 to 5.017 in 2016. Lower leg and foot were the most frequent anatomic sides of treatment counting up to 83.9% of all cases. In addition, MDT procedures for temporary soft tissue coverage including negative pressure wound therapy were often performed: for treatment of large areas in 36.7% and small areas in 6.2%. 41.3% of all cases treated with MDT had infection with Escherichia coli and 35.9% of all cases with Bacillus fragilis. Our analysis shows a limited use of MDT with a small increase only in the last 6 years in German hospitals. MDT is predominately used to treat foot or leg ulcers.

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.

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.

Larval therapy applied to a large arterial ulcer: an effective outcome

This article is a review of larval therapy and includes a case study that uses larval therapy in the treatment of complex leg ulcer wounds. Complex wounds require careful management from the multidisciplinary team and present clinicians with intricate challenges to save the limb. Wound-bed preparation and debridement needs to be as effective and non-traumatic as possible for the patient. Larval therapy removes the devitalised tissue effectively with minimal tissue trauma. This case study reports on a patient with a non-progressing, full-thickness wound with exposed tendon following reconstructive surgery at a local vascular unit. The patient was left with very limited treatment options, as traditional dressings for the arterial ulcer nearly resulted in amputation due to the deterioration in the wound. As part of the patient's management, she was treated with larval therapy in an attempt to salvage her limb. This article follows the progress of complex leg ulcer wounds employing BioFoam® dressing (BioMonde, Bridgend) for larvae debridement therapy over a 4-week period and incorporating five applications of three BioFoam dressing bags. This care pathway ensured the patient's safety by promoting effective wound healing with the larval therapy leading to excellent clinical patient outcomes.

Treatment for lymphorrhoea in limbs and in advanced disease

Supported by the NHS Lymphoedema Service Administrator, this article reports on a project undertaken by a clinical nurse specialist in Lymphoedema (CNS) and in part fulfilment of an MSc in Skin integrity skills and treatment, achieved from the University of Hertfordshire, September 2011. The need for the project was generated by the 5-day delay experienced by terminally ill patients in a hospice while waiting to receive treatment for lymphorrhoea from the community-based CNS. The training and assessment of healthcare assistants in a cost-effective treatment enabled the instigation of care within 3 hours of the development of lymphorrhoea in a patient and an evaluation of its competent delivery.