Maggot debridement therapy: the current perspectives Gurudutt Naik, Keith G Harding Welsh Wound Innovation Centre, Cardiff University. Maggot therapy is also known as maggot debridement therapy (MDT), larval therapy, larva therapy, larvae therapy, bio-debridement or bio-surgery. It is a type of. Revived in recent years, maggot debridement therapy (MDT)—a type of biotherapy using live disinfected maggots as a form of wound care—is an effective.
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Maggot debridement therapy MDT is one alternative utilized with successful results. Observations have indicated that maggots have the ability to debride wound beds, provide anti-microbial activity and also stimulate wound healing in diabetic patients. None of the patients refused MDT due to aversion of this treatment modality and the majority of patients had minimal discomfort. Theraapy 17 of 23 patients with multiple co-morbidities, the treatment of their complex diabetic wounds by MDT resulted in improvement or cure.
Maggot debridement therapy is an effective treatment of diabetic wounds. Patients with diabetes have difficulty healing wounds. This is especially true in the elderly whose numbers are increasing, resulting in rising cost for the delivery of health care.
[Full text] Maggot debridement therapy: the current perspectives | CWCMR
The annual cost to manage these wounds exceeds 20 billion dollars, 1 with a loss of over two million work days. There are numerous dressings to choose from, with costly new products coming to the market on a monthly basis, all claiming to improve outcomes. Maggot Debridement Therapy MDT has been infrequently used in the last 60 years due to improved dressings, new surgical techniques, and the surge of new antibiotics to treat non-healing wounds when they become infected.
However, uncontrolled diabetics were excluded from the study. Patients with diabetic wounds were evaluated for MDT and written consent for treatment was obtained.
Each vial contained mavgot maggots that were viable long enough for two MDT treatments. Approximately 40—50 maggots were carefully inserted into the maggott bed with a sterile Q-tip and gauze moistened with saline was applied on top of the maggots. A bulky dressing was applied over the wound. The patients and family members were advised not to disturb the dressing and warned that they would see increased drainage.
The patients were then scheduled for follow-up appointments 48 hours later if they were out-patients, or treated in their hospital room 48 hours later if they were in-patients. After 48 hours the wound mesh was removed, and the maggots were then extracted from the wound with wall suction Figure 1.
If the wound was not completely debrided, maggots were reinserted and the wound covered debridwment with mesh. This cycle continued until full debridement was attained. The other eleven patients were all begun on MDT as out-patients.
These diabetic patients had the most challenging wounds for debridement often times due to compromised vascularity, not amenable to sharp debridement. Five patients were on chronic hemodialysis with end-stage renal disease ESRD.
maygot Eleven of the 23 patients’ wounds had extended to the bone with underlying osteomyelitis. Successful therapy was defined as full-debridement of the wound bed with enhanced granulation tissue formation with or without full closure of the wound. Often, MDT was followed by the application of negative-pressure wound dressings once satisfactory debridement was obtained. This encouraged the rapid formation of granulation tissue.
Contraindications to MDT were open wounds in large body cavities and wounds in close proximity to large blood vessels. The team avoided MDT in patients allergic to eggs, soybeans or fly larvae.
Coagulopathy was not a contra-indication but such patients were monitored closely since increased bleeding is common during therapy. The team began MDT in the fall of in a diabetic patient with a non-healing right hallux amputation. The wound would not close due to multiple co-morbidities end-stage renal disease, diabetes, and heart disease. A negative- pressure wound dressing led to necrosis of his toes due to insufficient arterial flow. He adamantly refused a below-the-knee amputation.
Previous studies 910 have demonstrated fewer amputations using MDT when compared to conventional therapy.
So, MDT was employed to assist in wound debridement and closure of the wound. Subtotal granulation occurred within one month, although devitalized bone still extruded from the wound. After three further months of MDT, complete debridement of exposed bone was obtained Figure 1. Over the past nine months the team has treated 23 diabetic patients with MDT.
Clinical outcomes are displayed in Table 1. In 17 of 23 patients, successful outcomes maggot achieved by MDT. These 17 patients exhibited complete debridement with the formation of robust granulation tissue within their wounds.
In fact, 6 of these patients formed granulation tissue over exposed tendons, avoiding tendon excision. While MDT may not completely close patients’ wounds, partial closure of wounds was obtained in all of the successfully treated patients.
For example, one patient with severe lymphedema had been treated since without any perceptible closure of his venous stasis ulcers. Two of the successfully treated patients required a skin graft to achieve full closure, and several others demonstrated further closure of their wounds with negative-pressure dressings. One patient with a large eschar over a below-knee amputation site demonstrated successful debridement of the eschar by MDT but initially did not exhibit granulation in the wound bed.
After 30 days, MDT was discontinued and a negative-pressure dressing was applied. After one week further deterioration of the wound bed was observed thought to be due to impaired arterial flow to the extremity. Wet-to-dry dressings were instituted and successful closure of the wound was obtained.
Another magggot feature observed during the treatment of diabetic patients with peripheral neuropathy was the return of normal sensation after several MDT treatments. Six of 23 patients did not significantly benefit from MDT.
Three patients who had osteomyelitis of the bones of their feet did not benefit from MDT due to narrow openings of their wounds i.
Maggot debridement therapy: the current perspectives
Robust granulation tissue formation induced febridement MDT led to closure of their wounds before the maggots were able to reach the necrotic bone for debridement. In patients that had sufficient exposure of bone, therapy was successful with an apparent halt of bony destruction. A fourth patient had a deep venous stasis ulcer with documented leukocytoplastic vasculitis.
The maggots ruptured a vein in her leg causing bleeding which necessitated early discontinuation of the MDT. She was not on anticoagulants. A fifth patient, severely debilitated from a coronary debfidement bypass graft, congestive heart failure, a cerebral vascular accident, and thrombocytopenia, was anti-coagulated with heparin.
The maggots that were placed in his foot ulcer caused excessive bleeding. In a sixth patient who was status-post surgical debridement of a wound, excessive inflammatory maggo at debrodement margins of the wound necessitated discontinuation of MDT. A negative-pressure dressing resulted in enlargement of the wound, which the team later realized was due to pathology, as she was then diagnosed as having pyoderma gangrenosum.
The inflammatory reaction disappeared within 24—48 hours following temporary interruption of MDT, which was thereafter resumed without a resumption of the exhuberant inflammatory reaction. None of the patients discontinued MDT due to an aversion of having maggots placed in their wounds. All of debrirement patients were agreeable to the therapy and most were enthusiastic about this treatment option. Several of the patients complained of discomfort requiring analgesics.
This has been previously reported in patients treated with MDT compared to conventional therapy. One patient temporarily interrupted therapy due to discomfort, but then resumed treatment a short time later without difficulty.
Maggot debridement therapy: the current perspectives | CWCMR
One patient had maggots escape after getting the dressing wet. A few of the health care professionals were squeamish about assisting in the application and removal of the maggots. Wound debridement, originally thought to be a mechanical effect of the maggots, 11 has been shown to be due to three proteolytic enzyme classes that were identified in the maggot excretions.
There have been several studies attempting to identify how the maggots increase granulation in the wound bed. A study conducted in demonstrated an increased migration but not proliferation of the fibroblasts which was attributed to the action of serine and metallo-proteinases.
The literature recommends not using maggots in a dry wound bed since they require a moist wound to survive. It is important to advise patients of increased drainage from their wounds while receiving MDT since several of the patients verbalized fear that their condition was worsening when they observed increased drainage.
MDT was a preferred method for patients who were not operative candidates due to their underlying vasculopathy. MDT is selective as maggots consume only necrotic tissue, leaving viable tissue intact. Patients needed reassurance that their wounds were not worsening when an exuberant inflammatory response surrounded their wounds. This disappeared in the majority of the patients in 24 to 48 hours, following temporary interruption of MDT.
The patient with pyoderma gangrenosum experienced continued inflammation for 96 hours, which was likely due to pathology. Maggots are able to debride diabetic wounds and stimulate wound healing.
This study demonstrates that MDT is an effective strategy for the treatment of complex, diabetic wounds. Furthermore, the authors have shown that MDT works in dry, gangrenous wounds as well. Patient acceptance of, and satisfaction with, MDT was excellent. The majority of the patients tolerated MDT well with only a few experiencing pain that was adequately controlled with oral analgesics. Inthe Food and Drug Administration approved medicalgrade maggots for the treatment of chronic wounds.
However this trial excluded uncontrolled diabetics. The authors report no conflicts of interest. National Center for Biotechnology InformationU.
Journal List Hawaii Med J v. Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Introduction Patients with diabetes have difficulty healing wounds. Methods Patients with diabetic wounds were evaluated for MDT and written consent for treatment was obtained.
Open in a separate window. Results The team began MDT in the fall of in a diabetic patient with a non-healing right hallux amputation. Table 1 Results of MDT. Discussion Wound debridement, originally thought to be a mechanical effect of the maggots, 11 has been shown to be due to three proteolytic enzyme classes that were identified in the maggot excretions. Conclusions Maggots are able to debride diabetic wounds and stimulate wound healing.