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Quote:-"The maggots do more than just clean a wound.
-They also dissolve the infected tissue,
-Kill bacteria,
-and leave an enzyme behind that stimulates healing.
-They will only eat the infected tissue,
-leaving healthy tissue alone."
"In general maggots have the capacity to distinguish viable and dead tissue on a cell-by-cell basis," Said Dr. Steven M. Holland Chief of the Laboratory of Clinical Infectious diseases at the National Institute of Allergy and Infectious Diseases. -:
Would that the powers that be could come round to using this as a more common practise at the pointy end of the NHS.?
Question:- "Does anyone know or have any idea of the failure rate for the MAGGOT TREATMENT before I get to enthusiastic about these little friends of ours? Perhaps there isn't one!"
YAHOO HEALTH NEWS 24.7.5. in the case of Barbara Enser 57yrs. old, Bay City Mich. USA. a diabetic for 40yrs. Lost left leg, right one was about to follow! A good healing outcome after the little darlings had done their worst, sorry best!
Dr. Gereld L. Dowling, Head of the Podiatry Section of the Orthopedics Dept. at Bay Regional Centre should be mentioned here as the Doctor who carried out the treatment on Barbara Enser.
Regards,
Colin.
PS. Hope your breakfast etc. has stayed down!
Last edited by C Bain : 24th July 2005 at 02:35 PM.
Reason: Recognition of doctor Dowling work on Patient Enser!
I have not any information to provide about the failure rate but have a further query regarding maggot therapy.
There is certainly some new evidence suggesting that it is a worthwhile option in some cases but there is little discussion of how useful the maggots are that end up there by themselves rather than being deliberately used as a mangement option.
In the past year I have had two people arrive in my clinic with larvae swarming through their wound- what are the thoughts regarding the benefit of this for the wound? I took the approach where if I hadn't deliberately put them there with a structured plan then the maggots weren't such a good idea and I flushed them away- but perhaps I should have left them????
They are starting to be more widely used - there have been several scientific publications on their use.
The news media love this topic. This was just on the news wires today:
Quote:
Bay City doctor uses maggots to help save foot of diabetes patient
July 23, 2005, 11:37 AM
BAY CITY, Mich. (AP) -- Barbara Enser wasn't very comfortable at first with the idea of using maggots to clean the wound on her right foot.
But if it meant saving it from amputation, she was willing to give it a try.
The 57-year-old Bay City woman was diagnosed with diabetes 40 years ago and subsequently lost her left leg to the disease. She also suffers from neuropathy, meaning she has no feeling in her foot or leg, and ulcers or wounds can develop from constantly putting pressure on the foot.
"I'm just hoping this works because I think this is the last straw for saving the foot," Enser told The Bay City Times before a recent treatment. "I don't like creepy, crawly things. I won't even kill a creepy, crawly thing."
Enser went through a number of other procedures to stem the infection that is spreading through her foot. She had the wound cleaned with a scalpel and has been on antibiotics.
But after those failed, she turned to Dr. Gerald L. Dowling, head of the podiatry section of the Orthopedics Department at Bay Regional Medical Center. He first treated Enser with maggots on July 6.
For the procedure, the maggots -- about 2 millimeters each in size -- are placed on the wound, then surrounded by an adhesive foam, clear tape, and a gauze bandage.
By July 8, the maggots had swelled to twice their normal size and eaten away part of the infection. When Dowling removed the bandages two days later, Enser's foot was looking better. Healthy, pink skin was replacing the dead tissue, and the swelling was down in her foot and ankle.
The maggots do more than just clean a wound. They also dissolve the infected tissue, kill bacteria and leave an enzyme behind that stimulates healing. They will only eat the infected tissue, leaving healthy tissue alone.
"In general, maggots have the capacity to distinguish viable and dead tissue on a cell-by-cell basis," said Dr. Steven M. Holland, chief of the laboratory of clinical infectious diseases at the National Institute of Allergy and Infectious Diseases.
As much good as the first treatment did, Dowling decided to go with one more treatment. And when the bandages from the second procedure were removed 72 hours later, Dowling deemed the procedure a success.
Once the bandages were taken off, the maggots were removed using tweezers and the area was rinsed with a saline solution. Dowling then cut away leftover dead skin.
Biological wound healing agents (ie maggots) have proven to be really successful, despite the rather unpleasant idea of it. When used in a well controlled way they really do a great job at gently, painlessly and very efficiently debriding necrotic tissue in indolent wounds.
The Podiatrists at Royal Hobart Hospital are using them (I hear this from the students we send on placement there). I'm not sure about other Pods using them - would be interested to find out.
From personal experience, rather than 'audit', I have found that maggots are excellent at removing dead tissue.
However, it seems that, particuarly in ischaemic wounds, they are not effective at desloughing the wound when the 'slough' is actually devitalised (ie not completely dead), and make very little difference to the wound.
So, in synopsis, I tend to use them on wounds that are necrotic, but will only use them on slough if I'm sure it is not devitalised tissue!
They are also quite expensive and they only provide an antimicrobial and desloughing function, they do not actually take the wound to healing, but can be very effective at speeding up the 'wound bed preperation' stage of ulcer treatment.
Unfortunatly in rural health care I get to see volunteer maggot therapy in action.I had a case of a diabetic ulcer patient that waited too long to come in.When I unwrapped the dressing his had brought his own maggots in with him.The patient did have an osteomyelitis and after realizing that amputation was necessary, did not return for treatment.My question now is did the maggots clean the bone as well as the tissue?I have since seen the pt in public and he seems fine.I am certain he never sought medical care elsewhere as we are the only podiatry dept.for 100 miles.Curious-trapperanne
OBJECTIVE: Pain as a complication of maggot debridement therapy (MDT) has been a topic of some controversy.This study set out to determine pain levels in patients treated with MDT.
METHOD: A retrospective analysis using a visual analogue scale (VAS) was performed: 41 patients were treated with MDT for non-healing wounds (22 men and 19 women; average age: 67 years).Average wound duration was 14 months (range: two weeks to 132 months). Maggots were applied using the contained or the free-range techniques. Paracetamol (1 g three times daily) and Durogesic plaster (25 microg every three days and 50 microg the day before the maggot change) were given for pain relief in the outpatient clinic.
RESULTS: Diabetic patients experienced the same amount of pain before and during MDT. Eight out of 20 non-diabetic patients experienced more pain during MDT than before; the remaining non-diabetic patients had the same amount of pain before and during the therapy.The difference between diabetic and non-diabetic patients was statistically significant (p<0.05) for all applications combined.
CONCLUSION: In 78% of patients (29/37) pain can be adequately treated with analgesic therapy. However, if pain is unmanageable in the outpatient department, we believe that options include hospital admission, using the contained method of application or, in the worst case scenario, cessation of treatment. A standardised but individually tailored pain management protocol is mandatory.
Why are the maggots expensive? Come to warm weather and leave something out, you will have maggot repopulation with a day or two at the most. South Florida there are many.
It is all to common for patients to come in with foot wounds contaminated with maggots. However from what I have heard there is only one particular type of maggot, as there several different types of maggots, that can be medically beneficial in wound care.
From what I remember, from a speaker at a wound care conference, some maggots can actually produce toxic by-produces detrimental to wound healing.
The advice was to remove any non-therapeutic maggots from wounds and reinforce hygiene and wound care.
A wriggling pile of stomach-churning maggots feast on a Christchurch Hospital patient's necrotic foot wound - but he's happy about it because the fly larvae may save his right leg from amputation.
"Some people can't get their head around it," the 55-year-old Christchurch businessman says. "But I'm happy to be the guinea pig. It's going to help me and it's going to help other people."
Maggot debridement therapy is regaining popularity around the world as a non-surgical way of cleaning chronic wounds.
The maggots secrete enzymes to liquidise dead tissue before eating it, eventually exposing healthy tissue.
The treatment has been used only a few times in New Zealand, and is a first for Christchurch, but there are now moves to introduce maggot therapy to Auckland.
The Christchurch patient, who declined to be named, said squeamish feelings stopped him looking at the maggots at first, but his curiosity eventually got too much.
"It's quite fascinating to see them racing around in there - they cause quite a stir."
He describes the sensation as like a moth flying into your ear - a fluttery fuzzy feeling.
Humour abounds as the man's wound dressing is changed and fat maggots pour out of his wound on to the sheet below.
"My wife moved out of the matrimonial bed because she was worried they would escape," he laughs.
The hospital's hyperbaric unit clinical charge nurse, Marj van der Linden, carefully puts the tiny maggots on to his wound, caging them with taped-down gauze.
Every couple of days, the full maggots are replaced by baby maggots the size of a grain of salt.
She said the man's wound had greatly improved after two applications of about 60 maggots over the past fortnight. The third batch was put in on Friday.
The man's doctor, vascular surgeon David Lewis, used maggots with huge success to treat wounds during his surgical training in the UK 10 years ago.
The treatment goes back to the Napoleonic wars in the early 1800s, when maggot-infested wounds were found to heal better than those without maggots. The same was found in World War I.
Lewis said suitable candidates were patients with poor circulation or wounds which were slow to heal.
"It's possibly going to lower the amputation rate and will allow patients a speedier recovery and limb function," he said.
"Rather than losing two toes, they might lose only one."
The Christchurch patient was diabetic and had his big right toe amputated in December. He was one day away from having his leg amputated when doctors decided to try other measures, including maggot therapy.
The maggots come from entomologist Dallas Bishop, who rears the European green blowfly maggots at the Wallaceville research centre in Upper Hutt.
Diabetes specialist podiatrist Angela Bayley plans to introduce maggot therapy at a new diabetes health service for Maori, starting in Auckland in April.
About 515 people a year lose a leg in New Zealand because of complications related to diabetes.
Re: A Creepy story for the gippy stomach amongst us!
Clinical and microbiological efficacy of MDT in the treatment of diabetic foot ulcers.
Tantawi TI, Gohar YM, Kotb MM, Beshara FM, El-Naggar MM. J Wound Care. 2007 Oct;16(9):379-83.
Quote:
OBJECTIVE: To assess the clinical and microbiological efficacy of maggot debridement therapy (MDT) in the management of diabetic foot ulcers unresponsive to conventional treatment and surgical intervention.
METHOD: Consecutive diabetic patients with foot wounds presenting at the vascular surgery unit and the diabetic foot unit of Alexandria Main University Hospital were selected for MDT. Lucilia sericata medicinal maggots were applied to the ulcers for three days per week. Changes in the percentage of necrotic tissue and ulcer surface area were recorded each week over the 12-week follow-up period. Semiquantitative swab technique was used to determine the bacterial load before and after MDT.
RESULTS: The sample comprised 10 patients with 13 diabetic foot ulcers.The mean baseline ulcer surface area was 23.5cm2 (range 1.3-63.1), and the mean percentage of necrotic tissue was 74.9% (range 29.9-100). Complete debridement was achieved in all ulcers in a mean of 1.9 weeks (range 1-4). Five ulcers (38.5%) were completely debrided with one three-day MDT cycle. The mean reduction in ulcer size was significant at 90.2%, and this occurred in a mean of 8.1 weeks (range 2-12). The mean weekly reduction in ulcer size was 16.1% (range 8.3-50). Full wound healing occurred in 11 ulcers (84.6%) within a mean of 7.3 weeks (range 2-10). The bacterial load of all ulcers reduced sharply after the first MDT cycle to below the 10(5) threshold, which facilitates healing.
CONCLUSION: The results highlight the potential benefits of MDT in diabetic wound care in developing countries. MDT was proved to be a rapid, simple and efficient method of treating these ulcers.
Re: A Creepy story for the gippy stomach amongst us!
Morning, afternoon & evening all,
Having seen larvae therapy (lil wriggly guys) in action in Doncaster Royal Infirmary some years ago I felt it a good idea to add the following positive note to this thread.
I attended the hospital to shadow the local wound care nurse specialist for the specific purpose of witnessing larvae therapy in action.
The maggots are ordered (for this area) & couriered to the hospital from a farm in Wales.
The wrigglers are cultivated in sterile conditions & dispatched at the optimum stage of development (unsure of actual stage of larvae but thread like in appearance about 2mm long).
They were applied to a sloughy wound on anterior L tibial area & left in situ for 3 days.
When the dressing was removed the necrotic area had been successfully debrided without the requirement for sharps being used.
Muscle & tendons were visible (patient had glove & stocking neuropathy & expressed he had no discomfort during the therapy).
The larvae had increased in size having digested the necrotic tissue. There was a distinct odour of ammonia on removal of the dressing, the wound base was clean in appearance.
The nursing team cleaned the wound with sterile saline & continued therapy with the application of appropriate dressings.
I contacted the wound care team approx 3 months later & was told that although the wound had not completely resolved, the patient continued to improve & was attending his district nursing team for twice weekly dressing changes.
I think an important benifit for many patients when using larvae therapy to debride wounds is that when used in patients who would perhaps not survive a general anaesthetic to permit surgical sharp debridement, an alternative is available.
I understand that locally the hospitals are also utilising leeches in post op. heamotoma care.
__________________
:)
twirly
Mandy Brooks
Brooks Podiatry
S64 0DE
Suffering a fondness for odd things.
Re: A Creepy story for the gippy stomach amongst us!
Quote:
Originally Posted by twirly
I think an important benifit for many patients when using larvae therapy to debride wounds is that when used in patients who would perhaps not survive a general anaesthetic to permit surgical sharp debridement, an alternative is available.
Hello Twirly,
Of course, another alternative to sharp debridement under general anaesthetic is sharp debridement under local anaesthetic. It's horses for courses really, but if there's underlying osteomyelitis they're probably better used as an adjunct rather than an alternative.
Re: A Creepy story for the gippy stomach amongst us!
Hi Bob,
Potentially yes but the added bonus with larvae therapy is I understand that they are unlikely to cause damage to viable tissue. Whereas even in the most capable of hands sharps can cause problems too.
Toeslayer, I followed your thread re: maggotts in a bag, seemingly more tolerable to certain patients. If similar outcomes can be achieved then surely a good idea.
Regards,
__________________
:)
twirly
Mandy Brooks
Brooks Podiatry
S64 0DE
Suffering a fondness for odd things.
Re: A Creepy story for the gippy stomach amongst us!
Maggot debridement therapy of infected ulcers: patient and wound factors influencing outcome - a study on 101 patients with 117 wounds.
Steenvoorde P, Jacobi CE, Van Doorn L, Oskam J. Ann R Coll Surg Engl. 2007 Sep;89(6):596-602.
Quote:
INTRODUCTION: It has been known for centuries that maggots are potent debriding agents capable of removing necrotic tissue and slough. In January 2004, the US Food and Drug Administration decided to regulate maggot debridement therapy (MDT). As it is still not clear which wounds are likely or unlikely to benefit from MDT, we performed a prospective study to gain more insight in patient and wound characteristics influencing outcome. PATIENTS AND
METHODS: In the period between August 2002 and December 2005, patients with infected wounds with signs of gangrenous or necrotic tissue who seemed suited for MDT were enrolled in the present study. In total, 101 patients with 117 ulcers were treated. Most wounds were worst-case scenarios, in which maggot therapy was a treatment of last resort.
RESULTS: In total, 72 patients (71%) were classified as ASA III or IV. In total, 78 of 116 wounds (67%) had a successful outcome. These wounds healed completely (n = 60), healed almost completely (n = 12) or were clean at least (n = 6) at last follow-up. These results seem to be in line with those in the literature. All wounds with a traumatic origin (n = 24) healed completely. All wounds with septic arthritis (n = 13), however, failed to heal and led in half of these cases to a major amputation. According to a multivariate analysis, chronic limb ischaemia (odds ratio [OR], 7.5), the depth of the wound (OR, 14.0), and older age (>or= 60 years; OR, 7.3) negatively influenced outcome. Outcome was not influenced by gender, obesity, diabetes mellitus, smoking, ASA-classification, location of the wound, wound size or wound duration.
CONCLUSIONS: Some patient characteristics (i. e. gender, obesity, smoking behaviour, presence of diabetes mellitus and ASA-classification at presentation) and some wound characteristics (i. e. location of the wound, wound duration and size) do not seem to contra-indicate eligibility for MDT. However, older patients and patients with chronic limb ischaemia or deep wounds are less likely to benefit from MDT. Septic arthritis does not seem to be a good indication for MDT.
BACKGROUND: Debridement is considered an essential component of wound bed preparation. Multiple techniques for removing necrotic tissue from wounds have been identified, but evidence concerning the efficacy and indications for each technique varies.
OBJECTIVES: We sought to identify evidence related to the efficacy of maggot (larval) debridement for the removal of necrotic tissue and its impact on wound healing.
SEARCH STRATEGY: A systematic review of electronic databases was undertaken using the following key words: (1) debridement, (2) maggot therapy, and (3) larval therapy. All prospective and retrospective studies published between January 1960 and February 2008 that compared maggot (larval) debridement therapy for pressure ulcers, leg ulcers, or burn wounds to autolytic debridement or other debridement techniques were included in the review.
RESULTS: The evidence base for the efficacy of maggot debridement therapy (MDT) in the management of necrotic wounds is sparse. There is insufficient evidence to conclude that MDT is as effective as or more effective than other debridement methods, or that MDT promotes wound healing.
IMPLICATIONS FOR PRACTICE: Even though clinical evidence supporting the use of MDT for debridement of wounds is lacking, clinical experience strongly suggests that this technique is an effective and safe method of debridement for selected patients. Expert clinicians with extensive experience using this technique usually advocate MDT as a last resort treatment when conservative
Re: A Creepy story for the gippy stomach amongst us!
The evidence base for the efficacy of maggot debridement therapy (MDT) in the management of necrotic wounds is sparse. There is insufficient evidence to conclude that MDT is as effective as or more effective than other debridement methods, or that MDT promotes wound healing
With greater experience much has been learned about the practical use of maggots. Used properly they demonstrate incredible wound changes in a short period of time. Used inappropriately they just add a source of dead protein to the wound that bacteria will enjoy and thrive upon.
- Maggots work best for fully exposed wounds without deep sinus tracts.
- There must obviously be zero pressure on the wounds or they will be crushed and die instantly. Zero pressure on diabetic wounds should be a goal anyway for ideal healing.
- They will work well on soft tissue but not bone. They may help clean some microbes on the bone but maggots are not a substitute for the surgical excision of necrotic bone.
- There must be an adequate blood supply. Maggots do not work well on ischemic wounds. A vascular consult is imperative for patients with ischemic wounds.
- If there is no drainage from the maggot dressing within 12-18 hours the maggots are most likely dead and the patient is advised to come in right away to remove and change the dressing.
- The dressings must be changed frequently. The outer dressing that fills with drainage should be changed at least three times daily and the maggots removed every 48 0 72 hours and replaced with a new, fresh, hungry batch.
- The use of maggots is a painless means of treatment for diabetics with a significant neuropathy. On other types of ulcers in patients with normal sensation it can be a very painful form of treatment.
In some patients, two or three maggot dressing changes seems to stimulate the wound to heal while in others the maggots must be used almost continuously to wound closure. While they don't always work, the results when they do (which is most of the time) are often dramatic.
Ironically, the biggest barrier to the use of maggots is not squeamishness on the part of patients but on the part of doctors and nurses. VERY few of my patients have refused their use. Faced with a potential amputation it has seemed like a tolerable means of treatment for many.
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Re: A Creepy story for the gippy stomach amongst us!
Quote:
Originally Posted by twirly
Hi Bob,
Potentially yes but the added bonus with larvae therapy is I understand that they are unlikely to cause damage to viable tissue. Whereas even in the most capable of hands sharps can cause problems too.
Regards,
Yeah, like I said, horses for courses. I don't fancy a maggot's chances of gnawing through enough bone to give you a clear margin for a ray resection in an osteomyelitis case. Saw wins.
Re: A Creepy story for the gippy stomach amongst us!
Maggot debridement therapy with Lucilia cuprina: a comparison with conventional debridement in diabetic foot ulcers.
Paul AG, Ahmad NW, Lee HL, Ariff AM, Saranum M, Naicker AS, Osman Z. Int Wound J. 2009 Feb;6(1):39-46.
Quote:
This is prospective case-control study of more than 18 months performed to assess the effectiveness of maggot debridement therapy (MDT) with the sterile larvae of Lucilia cuprina (a tropical blowfly maggot) for the treatment of diabetic foot ulcers. Literature thus far has only reported results with the temperate maggot, Lucilia sericata. This study documents outcome in diabetic foot wounds treated with maggot debridement versus those treated by conventional debridement alone. In this series of 29 patients treated with MDT, 14 wounds were healed, 11 were unhealed and 4 were classified under others. The control group treated by conventional debridement had 30 patients of which 18 wounds were healed, 11 unhealed and 1 classified under others. There was no significant difference in outcome between the two groups. The conclusion that can be made from this study is that MDT with L. cuprina is as effective as conventional debridement in the treatment of diabetic foot ulcers. It would be a feasible alternative to those at high risk for surgery or for those who refuse surgery.
Re: A Creepy story for the gippy stomach amongst us!
Reuters are reporting: Maggots no wonder cure for festering wounds
Quote:
Putting flesh-eating maggots into open wounds may not be such a great idea after all.
They do clean wounds more quickly than normal treatment but this does not lead to faster healing, results of the world's first controlled clinical trial of maggot medicine showed on Friday.
Some patients also found so-called larval therapy more painful, according to the study in the British Medical Journal.
Gruesome as it sounds, maggots have a long history in medicine. Napoleon's battle surgeon was a maggot enthusiast, and they were put to work during the American Civil War and in the trenches in World War One.
More recently, medical experts have been looking again at the creatures' healing powers, including their potential to prevent dangerous infections like methicillin-resistant Staphylococcus aureus (MRSA).
To find out more, researchers at Britain's University of York recruited 267 patients with venous leg ulcers and treated them either with maggots or hydrogel, a standard wound-cleaning product.
They found no significant difference in outcomes or cost.
"It doesn't seem to be worth pursuing in this particular group of patients, if what you are aiming for is quicker healing," researcher Nicky Cullum said in a telephone interview....
Larval therapy for leg ulcers (VenUS II): randomised controlled trial
Jo C Dumville, Gill Worthy, J Martin Bland, Nicky Cullum, Christopher Dowson, Cynthia Iglesias, Joanne L Mitchell, E Andrea Nelson, on behalf of the VenUS II team BMJ 2009;338:b773
Quote:
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
Maggots / Larval Therapy
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