Wednesday, October 31, 2007

Maggot Therapy

When I was a general surgery resident, we had a couple of patients come in with maggots in their wounds--both with venous stasis ulcers on their legs. As "icky" as it was to clean the maggots out of the wounds, it was down right impressive how clean the wounds were (and yes it was my job to do the cleaning). Those maggots sure had done a wonderful job of removing the necrotic tissue and leaving behind healthy granulation tissue. (photo credit) So for Halloween, how about some bug therapy.

Maggot therapy waxes and wanes in popularity throughout time. Ambroise Pare (1509-1590) is generally given credit for first noting the beneficial effects of maggots in suppurative wounds. Napoleon's famous military surgeon, Baron D. J. Larrey (1766-1842) noted larvae of the blue fly in the wounds of soldiers in Syria during the Egyptian expedition. He noted that the maggots only attacked putrefying substances rather than living tissues and that they promoted their cicatrization. W. W. Keen commented on the presence of maggots in wounds during the Civil War, saying that the maggots were disgusting but did no apparent harm. The first scientific study of the use of maggots was done by Dr. William S. Baer of Baltimore, Maryland. He first mentioned this "viable antiseptic" for the treatment of chronic osteomyelitis in a discussion following an article by Bitting that appeared in 1921. Baer commented on the clean wound of two soldiers with neglected compound femur fractures and abdominal wounds who had lain neglected for 7 days on the battlefields of World War I in 1917. Inspection of the wounds showed that they were infected with thousands of maggots, but had healthy granulation tissue beneath. At that time, the mortality from such wounds with the best medical care was close to 75%, and therefore the maggots made a profound impression. He went on to study maggots in detail.

Maggots, by definition, are fly larvae, just as caterpillars are butterfly or moth larvae. Phaenicia sericata (green blow fly) larvae is the one used in maggot therapy.

A drawing of the life cycle of this fly appears below. (photo credit)

One-day-old larvae are only about 2 mm in length, and almost transparent. By the time the maggots are 3 or 4 days old, they have grown to about 1 cm (1/2 inch) long. (photo credit)

Maggot Therapy

Maggots may be used intentionally as biological debriding agents. They are an effective alternative to surgical debridement in patients who cannot go to the operating room for medical reasons. It is the larvae of the green blowfly (Phaenicia sericata) that is used. This larvae is sterilized with radiation before being used so that they will not be able to convert from the larvae to the pupae stage. They secrete enzymes that dissolve the necrotic tissue and the biofilm that surrounds bacteria. This forms a nutrient-rich liquid that larvae can feed on. Thirty larvae can consume 1 gram of tissue per day. They are placed on wounds and covered with a semipermeable dressing. The debridement is painless, but the sensate patient can feel the larvae moving. More importantly, maggots help to sterilize wounds, because they consume all bacteria regardless of their resistance to antibiotics (including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus). Maggots have to be replaced every 2 to 3 days. Maggot therapy can be administered on an outpatient basis, provided that visiting nurses are familiar with their use. This is a good technique for painlessly removing necrotic tissue and destroying antibiotic-resistant bacteria in patients who cannot undergo surgical debridement for medical reasons. They work well in infected and gangrenous wounds, with the best results reported in diabetic wounds.

Medical grade larvae are available from Zoobiotic Ltd and Monarch Labs.

HAVE A SAFE 'HAPPY HALLOWEEN'!

References

Maggot Therapy: The Surgical Metamorphosis; Plastic & Reconstructive Surgery. 72(4):567-570, October 1983; Pechter, Edward A. M.D.; Sherman, Ronald A. B.S.

From the Bible to Biosurgery: Lucilia sericata--Plastic Surgeon's Assistant in the 21st Century; Plastic & Reconstructive Surgery. 117(5):1670-1671, April 15, 2006; Whitaker, Iain S. M.A.Cantab., M.R.C.S.; Welck, Matthew M.B.Ch.B.; Whitaker, Michael J. M.A.Cantab.; Conroy, Frank J. M.R.C.S.

Maggot Debridement Therapy; Plastic & Reconstructive Surgery. 120(6):1738-1739, November 2007; Mumcuoglu, Kosta Y. Ph.D.

Clinical Approach to Wounds: Debridement and Wound Bed Preparation Including the Use of Dressings and Wound-Healing Adjuvants; Plastic & Reconstructive Surgery. Current Concepts in Wound Healing. 117(7S) SUPPLEMENT:72S-109S, June 2006 ; Attinger, Christopher E. M.D.; Janis, Jeffrey E. M.D.; Steinberg, John D.P.M.; Schwartz, Jaime M.D.; Al-Attar, Ali M.D.; Couch, Kara M.S., C.R.N.P., C.W.S.

Maggot Therapy Project

6 comments:

mark a said...

As a medical resident I had a VA clinic every other week. One of my patients had a lower extremity ulcer due to long standing DM and PVD. One day he came to clinic and his wound looked the best I had ever seen it. He said that he was sitting on his porch one day and a fly landed on it, a few days later he noticed some maggots so he just let them be. I'm thinking, doesn't this guy ever take a shower?

I had several other patients admitted to my service for 'wound care' after the surgical residents cleaned off maggots from their open ulcers in the ER. I miss the VA.

Femail doc said...

I must admit even for me (who never flinched at icky pictures in my dad's medical books) the opening picture to this post which loads up way before any of your comments was a bit of a show stopper.

And somehow your closing 'HAVE A SAFE 'HAPPY HALLOWEEN'! after all that maggot talk cracked me up. Maggot therapy I can deal with, but leech therapy creeps me out. Yet recent leech work suggests that a little leeching can leach out the pain of an arthritic knee. I may someday sign up!

Val said...

Maybe the recent MRSA scare should be followed by the suggestion of maggot therapy? Consumers would LOVE it. Ha.

Chrysalis Angel said...

Oh, Ramona..glad I missed this post earlier. I can handle most stuff, but creepy crawlies are not my favorite thing.

megs said...

A a RN in Australia I wish our authorities were a bit more adventurous towards alternatives to drugs sometimes!!! Honey, Silver and spray on skin have all been accepted well, the maggot is tops for speed,efficiency and accuracy in those wounds that just wont heal. Poor old thing beavers away in the dark doing its job with no thanks! needs a good PR company I think!!

rlbates said...

Megs, I would agree with you about the PR. Take care.