Within 2 weeks, maggot-treated wounds were left with only 7% necrotic tissue (0.9 cm²) compared to 39% necrotic tissue (3.1 cm²) in the control group and all maggot-treated wounds were completely debrided within 4 weeks, while most control wounds were still over 33% covered with necrotic tissue. Protect your wound from infection by cleaning and covering them 3d. Hobson 22). There should be no more doubt that maggots secrete and excrete potent antimicrobial compounds. 9, no. The best way to consider the role of maggots in wound healing may be to first review the wound healing process in general and then to separately summarize the literature concerning each major wound healing effect of the maggots. Repeated measures ANOVA indicated that treatment rendered was the only factor associated with these differences. The authors concluded that containment of maggots reduced the effectiveness and efficiency of maggot debridement therapy, probably by preventing contact with, and/or complete access to, the wound bed. 2017;29(12):367-373. https://www.medscape.com/viewarticle/891517. Their findings of elevated cAMP and suppressed proinflammatory responses (without a measurable decrease in antimicrobial activity) led the authors to conclude that the larval secretions were moving the monocytes and neutrophils forward from the proinflammatory phase and into the angiogenic phase of wound healing 87). It is in this context that debridement, disinfection, or cellular proliferation and migration are so important, for they can push the stagnant wound into the next phase of healing. 163, no. M. J. None of the control wounds were debrided by more than 50%, even with 4 weeks of treatment. Growth effects of Phaenicia sericata larval extracts on fibroblasts: mechanism for wound healing by maggot therapy. 1997;60(8):505–510. 30, no. Scientists control wound myiasis by carefully selecting the species and strain of fly, the species most commonly used is the blowfly Lucilia (Phaenicia) sericata, disinfecting the larvae, using special dressings to maintain the larvae on the wound, and integrating quality control measures throughout the process 2). Larval therapy in wound management: a review. P. Steenvoorde, C. E. Jacobi, and J. Oskam, “Maggot debridement therapy: free-range or contained? A Handbook of Maggot-Assisted Wound Healing. Nonsupportive data were also available, though less commonly. Disturbances in wound healing can occur when one group of proteases is deficient or out of balance with another. But maggot therapy is one of the few highly effective methods of debridement which can safely and inexpensively be continued throughout the healing process, which may explain why it remains one of the methods of maintenance debridement best associated with faster wound healing. Biofilm is a particularly difficult problem in chronic wounds. Wayman et al 98) compared the cost of larval therapy with hydrogel dressings in the treatment of necrotic venous ulcers. 2, pp. W. S. Baer, “The treatment of chronic osteomyelitis with the maggot (larva of the blow fly),” Journal of Bone and Joint Surgery, vol. In a prospective study of spinal cord injury patients with chronic, nonhealing pressure ulcers, patients were followed for 3-4 weeks while receiving standard wound care (whatever modality was prescribed by the surgically led wound care team), followed by 3-4 weeks of maggot therapy 70). With recent advances in cellular biology and chemistry, we now know that maggot alimentary secretions and excretions stimulates the proliferation of fibroblasts 64) and endothelial tissue (unpublished data), increases angiogenesis 65), and enhances fibroblast migration over model wound surfaces 66). Mechanisms of maggot-induced wound healing: what do we know, and where do we go from here?. was one of the first investigators to systematically demonstrate proteolytic activity of Lucilia sericata larval digestive enzymes. By 2010, Cerovský et al. A. van der Plas, J. T. van Dissel, and P. H. Nibbering, “Maggot secretions skew monocyte-macrophage differentiation away from a pro-inflammatory to a pro-angiogenic type,” PLoS ONE, vol. 3, pp. R. P. Hobson, “On an enzyme from blow-fly larvae (Lucilia sericata) which digests collagen in alkaline solution,” Biochemical Journal, vol. Home > Clinical Articles > Pressure Injury > Using maggots in wound care: Part 1. 1, pp. 2016;115(6):2403–2407. Maggot infestation of wounds requires immediate medical attention as the condition tends to get worsened every day. Some clinical studies do not demonstrate these effects; instead, they leave doctors with doubts about the clinical significance of the wound healing activities that scientists see in most other clinical and laboratory studies. Valachová and colleagues 50) demonstrated that lucifensin expression was increased in response to microbial ingestion only in the fat body; lucifensin was expressed in the salivary glands throughout the larval period and not significantly affected by microbial ingestion. 77), intended to evaluate maggot-induced wound healing in venous stasis ulcers. U. Wollina, K. Liebold, W. Schmidt, M. Hartmann, and D. Fassler, “Biosurgery supports granulation and debridement in chronic wounds—clinical data and remittance spectroscopy measurement,” International Journal of Dermatology, vol. 4. Picking out maggots from the wound using forceps after applying local anesthesia is a common form of treatment. While this can be thought of as a subset of actions which promote wound healing, they are separated out for the purpose of this discussion because these actions may also play important roles in disinfection, if not also debridement. Many therapists prescribe brushing to rid a wound of biofilm. Maggots are very good at eating dead tissue and cleaning out wounds, but we typically want to use medical-grade maggots in a clinical setting. A. Although maggots are disgusting and creepy, they are not always bad. Most, though not all, laboratory studies comparing free range versus contained maggots have suggested that maggots in direct contact with the wound are more effective, at least for debridement, than maggots separated from the wound by their containment dressings 35). The physical movement of the maggot over the wound, plowing the tissue and spreading its alimentary secretions and excretions as it goes, contributes significantly to the debridement effort. 916–917, 1957. 267–271, 1935. The use of maggots has become increasingly important in the treatment of nonhealing wounds, particularly those infected with the multidrug-resistant pathogen, methicillin-resistant Staphylococcus aureus (MRSA). But ever since maggot therapy became a common practice 9), careful observers also noted other effects on the wounds: microbial killing (disinfection) and hastened wound healing (growth stimulation) 10). 4, pp. 3, pp. P. Steenvoorde and G. N. Jukema, “The antimicrobial activity of maggots: in-vivo results,” Journal of Tissue Viability, vol. To treat myiasis in dogs, you have to clean the wound. 4, pp. 505–510, 1997. 15, no. The necrotic tissue liquefies, and the maggots can then easily imbibe it. Exposing unstimulated human neutrophils to crude L. sericata salivary gland extract, Pecivova and colleagues 84) measured no effect on superoxide generation or myeloperoxidase (MPO) release. DNAse may play an important role not only in debridement but also in inhibiting microbial growth and biofilm. 10, no. The infestation of the tissues and organs of living vertebrates by dipteran larvae (maggots) is known as myiasis. Their results may have resulted from the decreased competition by gram positive microbes. 9, pp. 6, pp. Z. Zhang, S. Wang, Y. Diao, J. Zhang, and D. Lv, “Fatty acid extracts from Lucilia sericata larvae promote murine cutaneous wound healing by angiogenic activity,” Lipids in Health and Disease, vol. Wounds that really have quite a bit of dead tissue. 667–674, 2013. Anecdotal evidence of maggot therapy efficacy is plentiful, but large prospective comparative clinical trials are desperately needed. 2007;83(980):409–413. 91–94, 2000. In the 140-subject randomized controlled trial by Markevich and colleagues 76), wounds treated with maggot therapy were ultimately covered with more granulation tissue and were smaller in size than the wounds in the control study arm. Tissue quality and wound size were assessed and photographed weekly. 2002;41(10):635–639. Numerous case reports have purported wound disinfection following maggot therapy, but controlled clinical evidence of maggot-induced antimicrobial activity has been sparse, until recently. Maggot debridement therapy shortens healing and disinfects wounds. Maggots are the small, slimy larvae of the common household fly, and they can grow in any region that is moist, dark and secluded. Treatment with intravenous sodium thiosulfate (STS) was initiated and titrated to 25 g/d. Maggot therapy is a real thing, that is really gross, and that really works. Excretions/secretions from medicinal larvae (Lucilia sericata) inhibit complement activation by two mechanisms [published online ahead of print December 26, 2016]. Depending on the size and depth of the wound, 50 to 1000 sterile maggots, about 24 to 48 hours old, are applied 2 to 4 times per week and left on for a period of 24 to 72 hours 94). 5, pp. Larvae are covered by minute spines which scrape along the wound base as the maggots crawl about, loosening debris as does a surgeon’s rasper or file (Figure 1). 2017;25(1):41–50. In order to debride necrotic tissue, larvae (ie, maggots) produce a mixture of proteolytic enzymes, including collagenase, that breaks down the necrotic tissue to a semi-liquid form to be absorbed and digested. Once they are located, the maggots will have to be manually extracted from the skin of the cat. Semiquantitative cultures were taken at baseline and before each cycle of maggot debridement therapy. 10, no. Tissue quality and wound size were assessed weekly. 523–531, 2010. 6, pp. 73), was defined as the change in surface area divided by the mean circumference over time. For these reasons, maggot debridement was approved by the US Food and Drug Administration in 2004 21). M. Bradley, N. Cullum, and T. Sheldon, “The debridement of chronic wounds: a systematic review,” Health Technology Assessment, vol. The maggot-treated group displayed more anxiety and wound odor during treatment, but no greater pain or other adverse events. These were small, due to a lack of funding and support; but they showed the promising results needed to propel maggot therapy into the scientific limelight and justified larger and more definitive studies. Patients were randomly assigned to two equal intervention and control groups. Antimicrobial killing also occurs outside the maggot’s gut, and the extracorporeal secretion/excretion of antimicrobial compounds may even be responsible for most of the maggot’s antimicrobial activity 41). Maggots have been used as a wound therapy since the beginning of civilization (1). Wound healing is classically described as 4 distinct but overlapping physiological phases of repair and rebuilding 17): With each phase, new cells are recruited into the area to perform the work, or cells already present alter their activity to secrete new cytokines or perform new duties, in response to changing conditions in the wound (bleeding, hypoxia, alterations in cytokine concentrations, etc.). 353, no. Maggot therapy is a biotherapy in which live, disinfected maggots (fly larvae) are placed in a non-healing wound to eat the necrotic tissue and disinfect the wound. 93, no. They also pointed to the antimicrobial activity of ammonia-containing byproducts of the maggots’ digestion of tissue proteins and the resulting alkalinized wound bed 42). There is evidence that maggot therapy may help with wound healing. Complications. This 10-day long clinical trial failed to show any significant difference in wound healing between the maggot debridement therapy arm (60% healed by day 10) and the control arm (34% healed by day 10), but it is generally believed that the lack of any significant difference may be due to the fact that this 10-day debridement study was much too short to detect any meaningful wound healing. 430–435, 2005. (adsbygoogle = window.adsbygoogle || []).push({}); (adsbygoogle = window.adsbygoogle || []).push({ 25, pp. 59) probably best addressed the clinical relevancy of maggot-induced disinfection by designing a case-control study of maggot therapy for lower extremity wounds in hospice patients and recording the antibiotics prescribed by the patients’ primary clinicians, as a measure of clinically significant infection. Maggots also fight bacteria in their more resistant form: biofilm. BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b773. Experiments performed by Barnes et al 20) have demonstrated that the blowfly Lucilia sericata (Lucilia (Phaenicia) sericata) larvae excretions/secretions are able to inhibit bacteria growth in both stationary and exponential phases. 18, no. Tamura T, Cazander G, Rooijakkers SH, Trouw LA, Nibbering PH. E. R. Pavillard and E. A. Wright, “An antibiotic from maggots,” Nature, vol. Several comprehensive reviews have been published over the past decade 13), 14), 15). 20, pp. The physical action of the maggot over the wound is a primary reason given by the FDA for classifying medicinal maggots as a medical device and not a simple drug. Keep the turpentine-soaked bandage on the wound for up to 1 hour, inspecting it from time to time 1. The present study was conducted to investigate the effect of Lucilia sericata maggot therapy in chronic wound treatment. 4, pp. J Microbiol Meth. 635–639, 2002. Often, the isolated molecules were more active against gram positive bacteria than gram negatives, but sometimes this was merely a matter of dose and potency 44). 48) completely sequenced the 40-residue defensin-like antimicrobial peptide now called: “lucifensin.” Altincicek and Vilcinskas 49) used suppression subtractive hybridization to show that 65 Lucilia sericata genes upregulated in response to septic challenge (cuticular puncture) with lipopolysaccharide. Prete 91) demonstrated that hemolymph and alimentary secretions of larvae were growth stimulatory for in vitro human fibroblasts. Diabetes Metab Res Rev. In a similar cohort of 18 diabetic subjects with 20 nonhealing neuropathic and neuroischemic foot ulcers 31), maggot-treated wounds were 50% debrided within an average of 9 days, but control wounds did not achieve that level of debridement until an average of 29 days. But what is the evidence that maggots bring about clinically relevant disinfection? 418–421, 1993. 180, no. 12–14, 2010. Valachova I, Takac P, Majtan J. Midgut lysozymes of Lucilia sericata – new antimicrobials involved in maggot debridement therapy. The physical mechanics of maggot debridement 19) are readily apparent to anyone who has seen the larvae under the microscope. Bexfield A, Nigam Y, Thomas S, Ratcliffe NA. The maggot does not “bite off” pieces of tissue, but it rather secretes and excretes its digestive enzymes (alimentary secretions and excretions or ASE), the consequence of which is that digestion begins in the wound bed, outside of the maggot’s own body. 468, no. Pressure Injury, Skin Tear & Treatment, Wound Care Advisor 2014 Journal Vol3 No4, WCA, wound infections Posts navigation. WATCH: Worst Maggots in wounds coming out after removed and treatment. Maggots were booming in the early 20th-century, when William Baer, an orthopedic surgeon at a children’s hospital in Baltimore and Johns Hopkins University, used maggots to clean the wounds of children with infections caused by tuberculosis. 3, no. 4, no. R. D. Wolcott, J. P. Kennedy, and S. E. Dowd, “Regular debridement is the main tool for maintaining a healthy wound bed in most chronic wounds,” Journal of Wound Care, vol. Nevertheless, 4- and 8-week healing rates were significantly better for maggot-treated wounds than control wounds, as was the weekly decrease in surface area and the rate of granulation tissue growth over the base of the wound. Matrix metalloproteinases (MMPs) play critical roles in all phases of tissue repair and wound healing, including hemostasis, thrombosis, inflammatory cell activation, collagen degradation, fibroblast and keratinocyte migration, and tissue remodeling. G. R. Erdmann and S. K. W. Khalil, “Isolation and identification of two antibacterial agents produced by a strain of Proteus mirabilis isolated from larvae of the screwworm (Cochliomyia hominivorax) (Diptera: Calliphoridae),” Journal of Medical Entomology, vol. maggot or larval therapy) is a promising adjunct to the whole spectrum of topical treatment methods, in particular for debridement. Maggot therapy is administered by applying sterilized fly larvae to the wound at a density of 5 to 8 per cm² 6). 370–371, 2007. 95–101, 1990. 2, pp. 18, no. 2008;24(Suppl 1):S76–S80. 446–451, 2003. Lucilia sericata larvae digest necrotic tissue and pathogens; they discriminate between necrotic and healthy (granulating) tissue. The dressing is finally covered with a simple absorbent pad held in place with adhesive tape or a bandage  7). enable_page_level_ads: true 1458–1463, 1931. This technique is rapid and selective, although some of the evidence to support its use is still derived from anecdotal reports 93). 1-2, pp. 67–73, HMP Communications, Malvern, Pa, USA, 4th edition, 2007. This study revealed significantly fewer days of antibiotics compared to controls, over a 6-month observation period, indicating that the patients were cleared of their infection faster and remained infection free longer. R. A. Sherman, “Maggot therapy for treating diabetic foot ulcers unresponsive to conventional therapy,” Diabetes Care, vol. Early clinical reports of maggot-induced wound healing were merely case studies or series; but beginning in the 1990’s, controlled comparative trials of maggot therapy began to appear. In fact, today, allantoin and urea are components of many cosmetics. Among the early theories about maggot-induced wound healing were that the simple removal of debris and microbial killing 61) or the action of crawling over the clean wound bed 62) might be enough to stimulate wound healing. Newspapers have taken slightly different angles on a study into the use of larval therapy for leg ulcers. S. E. Gill and W. C. Parks, “Metalloproteinases and their inhibitors: regulators of wound healing,” International Journal of Biochemistry and Cell Biology, vol. Apply the gauze soaked bandage to the open wound 1. Clinical evidence of maggot-induced disinfection and growth stimulation was not strong enough to convince regulators at that time. But when opsonized zymosan stimulated neutrophils were exposed to high concentrations of the salivary gland extract, superoxide generation and MPO release were significantly reduced. In this study population, the probability of healing may have had more do to with the patients’ underlying circulatory compromise, malnutrition, and poor physiologic health than with the treatments rendered. A cohort of 63 patients with 92 pressure ulcers was prospectively followed for at least 8 weeks while receiving either standard wound care (as prescribed by the hospital’s wound care team) or maggot therapy (two 48- to 72-hour cycles per week) 71). Many clinicians intuitively feel that faster debridement brings faster wound healing. Ophthalmic myiasis – maggot … Greenberg hypothesized that antimicrobial compounds might be produced in the gut by symbiotic microbes such as Proteus mirabilis, and, in 1986, Erdmann and Khalil identified and isolated two antibacterial substances (phenylacetic acid and phenylacetaldehyde) from the Proteus mirabilis that they isolated from the gut of a related blowfly larva: Cochliomyia hominivorax 40). Controlled studies of maggot debridement are less common, but quite worthy of examination. D. I. Pritchard, G. Telford, M. Diab, and W. Low, “Expression of a cGMP compatible Lucilia sericata insect serine proteinase debridement enzyme,” Biotechnology Progress, vol. Experiments performed by Barnes et al 89) have demonstrated that the blowfly Lucilia sericata (Lucilia (Phaenicia) sericata) larvae excretions/secretions are able to inhibit bacteria growth in both stationary and exponential phases. 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