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Maggot debridement therapy: advancing to the past in wound care.

Maggot debridement therapy (MDT) is an ancient wound care practice enjoying renewed popularity due to the occurrence of antibiotic-resistant organisms. Its first documented use goes as far back as the Bible, but it has been used throughout history by Maya Indians and on battlefields throughout the world (Rafter, 2013). In 1929, MDT was used by William Baer, an orthopedic surgeon at Johns Hopkins Hospital (Baltimore, MD) to debride wounds in children with osteomyelitis (Cazander, Pritchard, Nigam, Jung, & Nibbering, 2013). However, the discovery of penicillin overshadowed maggot research and led to widespread distribution of antibiotics in the 1940s (Cazander et al., 2013). Today, as incidence of antibiotic resistance increases, researchers and practitioners are returning to alternative therapies such as MDT to promote wound healing.

Overview

Maggot Application and Usage

Maggots, larvae of Lucilia sericata (see Figures 1 & 2), can be applied to wounds in two ways. In direct application, larvae are placed on the wound directly with a dressing applied over the maggots. With teabag application, larvae are gathered in a pouch similar to a tea bag and then placed into the wound. When first placed in the wound, larvae are 2-3 mm long; after being applied in the wound for 3-4 days, they grow to 8-10 mm. The larvae debride by eating necrotic tissue and slough, which are removed by the mechanical action of their mandibles and coarse bodies (Rafter, 2013). Medical maggots are supplied in sterile containers and have undergone a rigorous disinfection and sterilization procedure prior to medical usage (Paul et al., 2009).

Nursing considerations include pain management and maggot containment. Because patients will feel discomfort from the debridement process while maggots are in the wound, assessment and management of pain are needed while the maggots are in contact with the tissues. In addition, dressings should be inspected frequently. This assessment is especially critical when the direct application technique is used because maggots may escape the wound bed.

Dressings

Dressings for larval therapy need to be changed once daily, or twice daily if exudate is increased. Frequent dressing changes will decrease odor. The nurse should inform the patient the dressing may appear blood-tinged (Rafter, 2013).

Larvae need air and moisture to stay alive, so the dressing must be conducive to the maggots' survival. Netting generally is placed over the dressing to prevent maggot escape from the wound bed. Larvae are left in the wound for 3-4 days and are removed with forceps. The size of the larvae at extraction should be noted, and then the larvae should be placed in an appropriate biological waste bag. The wound is cleansed with normal saline after maggots are removed, and dressings are applied as indicated or MDT can be reapplied (Rafter, 2013).

Research Question

Many theories have been offered concerning the effectiveness of larval therapy in chronic wounds, such as pressure ulcers, diabetic foot ulcers, neurovascular and vascular wounds, osteomyelitis, postoperative infections, and burns (Rafter, 2013). One hypothesis suggests maggots have antimicrobial properties and anti-inflammatory effects on tissues. The standard of wound care is mechanical debridement (Mumcuoglu, Davidson, Avidan, & Gilead, 2012). A literature review was conducted to determine effectiveness of MDT compared to conventional mechanical debridement for nonhealing wounds. A secondary question addressed MDT as a viable option for healing chronic wounds and the circumstances in which it would be most effective.

Literature Review

A literature review was conducted to identify current evidence on the use of MDT. Inclusion criteria were primary evidence sources published 2002-2014 and relevant to the topic of MDT. The most current articles were selected for appraisal.

Search terms included maggot debridement therapy, larval therapy, Lucilia sericata, wound therapy, biotherapy, and conventional debridement. All terms were searched in Academic Search Premier. Numerous articles have been published over the past decade in Europe; they were included if they explained MDT, properties of maggots, pain, and perceptions and misconceptions. Other chosen articles compared effectiveness of MDT to conventional debridement, including cost variance. An older article (Sherman, 2002) was included because it provided the best comparison of MDT and conventional debridement therapy, a topic pursued by very few recent studies. Another article (Steenvoorde, Buddingh, Engeland, & Oskam, 2005) was included because authors discussed the patients' view of this unusual therapy; few other studies focused on the patients' acceptance and recommendation for the use of MDT. All other articles were published 2006-2013. Nine articles were selected based on relevance to the topic, current dates of publication, and ability to address the purposes of the literature review. The chosen articles were subjected to peer review prior to publication.

Results

Properties of Maggots

In a study assessing antimicrobial properties, Margolin and Gialanella (2010) compared the effectiveness of MDT on culture plates of methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, vancomycin-resistant Enterococcus, and Candida albicans. Maggots were placed in each of the plates for 5 days, and plates were tested every 24 hours. Fungi and bacteria were lysed completely when gram stained after 24 hours of maggot application. Bacteria or fungi remained absent over 5 days after maggots were applied, suggesting great promise for their use.

Maggots also may have an anti-inflammatory effect, as demonstrated by Cazander and colleagues (2012). Their research addressed the activity of the complement system, responsible for the inflammatory response in wounds, in relation to larval excretion. In chronic wounds, inflammation may become severe and damage tissues. Sera were obtained from four wounds before (control group) and after (experimental group) use of MDT. When compared, the post-treatment sera showed reduction of complement activity by up to 99.9% when compared to the control group; this effect was achieved by MDT breaking down complement proteins C3 and C4.

Pain

Pain from MDT was assessed over 4 years in 435 patients with 723 wounds (Mumcuoglu et al., 12). Maggots were applied using either direct or tea-bag application technique, with a range of 1-48 larval applications lasting 1-81 days. Five patients discontinued MDT due to unbearable pain, and approximately 40% (n=165) of patients reported increased pain with MDT. Participants' pain management strategies included oral paracetanol (Tylenol[R]), dipyrone (Analgin[R]) opioids, and peripheral nerve blocks for severe cases. Less pain was reported when using tea-bag application technique. The direct application of maggots appeared to cause more irritation to the wound bed from the mechanical action of the maggots' coarse bodies. Results suggest use of fewer maggots, tea-bag application, and appropriate pain management strategies can contribute to decreased pain during MDT.

Perceptions and Misconceptions

Research by Steenvoorde and coauthors (2005) considered the existence of the "yuk factor" of maggot therapy by studying 41 patients who used MDT therapy (either application technique) for their nonhealing wounds. Three nurses and three physicians were responsible for providing maggot care, and maggots were replaced every 3-4 days. On average, treatment lasted 11 days (three MDT treatments), and patients then were surveyed on their experience. Thirty-seven surveys were returned. Of participants, 89% indicated they would try MDT again and 94% would recommend it to others. A notable finding was the experience of adverse social reactions during MDT therapy by 22% of participants, apparently because they were undergoing an "eerie" practice (p. 2). While MDT generally is accepted by patients in treatment, this suggests the public needs better education on the usefulness of MDT for debridement of chronic wounds.

Although patients may be accepting of MDT, they cannot undergo treatment unless their health care providers prescribe it. A study by Heitkamp, Peck, and Kirkup (2012) addressed knowledge of MDT among U.S. Army physicians, who are more likely to use MDT than other providers because of their treatment of battle wounds. A sample of 181 physicians completed an online survey of 22 questions addressing their knowledge and possible practice of MDT, if they knew someone who used it, or if they knew it was approved by the U.S. Food and Drug Administration (FDA). Approximately 80% of physicians had heard about MDT, 10% had practiced MDT, 25% knew someone who used it, and 60% knew it was FDA-approved. MDT is accepted as a therapy in the Army, possibly because of its usefulness for veterans and wounded Soldiers. The biggest barrier to MDT use by Army physicians was their need for more information on its use, including cost, time, dressings, and availability. By association, Army nurses also need education on use of MDT for patients with chronic wounds.

The cost of maggot therapy largely is unknown by many physicians. MDT costs approximately $140 more per year than conventional debridement therapy with hydrocolloid dressings (Soares et al., 2009). However, from a study comparing 61 ulcers treated with MDT to 84 ulcers treated with conventional debridement, 80% of MDT wounds were debrided completely while only 48% of conventionally treated wounds were debrided completely (Sherman, 2002). Within 3 weeks, wounds treated with MDT had one-third the necrotic tissue and twice the granulation tissue of wounds debrided conventionally. MDT thus debrided necrotic tissue more effectively and promoted formation of granulation tissue to heal wounds more quickly than conventional debridement. This finding suggests maggot therapy can be applied for a shorter period of time and thus be more cost effective than conventional debridement. Health care providers should consider this when prescribing wound therapy.

Discussion

Antibiotic resistance has forced health care practitioners to look at other options to combat bacterial infection. Discussion of advantages, disadvantages, and nursing implications of MDT follows to assess its viability as therapy for patients with chronic wounds.

Advantages

Maggot debridement therapy is a natural way to debride wounds by lysing bacteria and fungi (Cazander et al., 2013). It also is an effective inhibitor of C3 and C4 inflammation proteins (Cazander et al., 2012). MDT is effective against resistant bacterial strains, does not harm healthy tissues, and promotes the growth of granulation tissue (Paul et al., 2009). Conventional debridement can harm healthy tissues while debriding necrotic tissue, which is why MDT may be a better alternative (Pettican & Baptista, 2012).

Physicians and patients seem to be willing to try MDT to debride hard-to-heal wounds (Heitkamp et al., 2012). Patients generally accept the therapy as a last resort to heal a wound or save a limb. The majority of patients who have undergone MDT would recommend it to others, which shows a general acceptance of and satisfaction in the therapy (Steenvoorde et al., 2005).

MDT has improved chronic wounds and reduced the amount of limb that must be amputated (Steenvoorde et al., 2005). Debridement is achieved better through MDT than conventional treatment because maggots feed off necrotic and infected tissues while leaving healthy tissues alone (Cazander et al., 2012). Also, on average, the treatment time is decreased significantly with MDT compared to conventional debridement alone (Jones, Green, & Lille, 2011).

Disadvantages

Maggot debridement therapy increased the amount of pain felt in 40% of patients. An effective protocol for pain management is needed to address this problem. Health care providers need to collaborate to manage patients' pain effectively. This can be done by using analgesia appropriate to the pain intensity and using tea-bag application versus placing the maggots directly in the wound (Mumcuoglu et al., 2012).

The biggest obstacle to MDT is the perception of society. Use of maggots in health care may seem unnatural (Steenvoorde et al., 2005). People need to become more informed about medical benefits of MDT for chronic wounds that currently are unmatched by any other wound care therapy. MDT has been researched widely in Europe and is used commonly for chronic wound healing. In the United States, better education is needed for health care providers concerning this viable wound care option (Heitkamp et al., 2012).

Usually, MDT is not discussed as an option for patients until a wound is so far advanced that amputation may be the only choice (Paul et al., 2009). Many physicians do not know how to obtain or use the maggot materials, or what the cost will be. MDT shows promise as a wound care practice with the progression of antibiotic-resistant bacteria; therefore, wound care physicians and nurses should be trained on MDT during their schooling or continuing education programs (Heitkamp et al., 2012).

Future Research

Future research should be conducted to determine if the antimicrobial, antifungal, and anti-inflammatory properties of MDT can be contained in topical or oral medications for wounds and inflammatory diseases or infections (Cazander et al., 2012). If creams and conventional medications can be developed with the same effects as maggot secretions, the societal stigma associated with MDT can be eliminated. However, medications would not provide the mechanical debridement of maggots.

Studies should compare pain experienced with conventional debridement versus MDT to differentiate pain intensity and determine pain management strategies. Patients need to be informed MDT may increase pain, and they need to decide if the benefits outweigh this possible disadvantage (Mumcuoglu et al., 2012). A sliding scale of pain medications based on the pain intensity should be established so physicians and nurses can manage pain associated with MDT. If pain is managed well, patients will be more likely to continue the therapy versus quitting due to unbearable pain.

Performing MDT on wounds in earlier stages with comparison to conventional debridement also should be done. If MDT works as well on earlier-staged wounds as it does on chronic wounds, the number of amputations and trips to wound care clinics could be reduced significantly (Paul et al., 2009). As a result, the cost of health care for these wounds would decrease. Many European studies have been published on MDT and its effects, but not as many recent studies have been published directly comparing the effectiveness of MDT compared to conventional debridement. Studies comparing these two therapies should relate their effectiveness with different types of wounds, different stages of wounds, and different placement of wounds.

Creating informative pamphlets for patients, families, and friends will help inform them about MDT: why the therapy was chosen, what it does, and how it may help (Steenvoorde et al., 2005). Distributing information may help decrease bias of family and friends, creating a better experience for the patient. This should be studied by comparing the adverse social reactions of patients undergoing MDT who give no information to family and friends versus patients undergoing MDT who give friends and family information.

Nursing Implications

As patient advocates, nurses should be knowledgeable about various types of wound care therapies. Education programs need to be established in wound clinics and hospitals to teach nurses about both conventional and alternative treatment methods. Nurses also need clinical training with maggots, dressings, and different application methods. MDT should be directed by specially educated wound care nurses, but clinical nurses can maintain and support MDT treatment (British Columbia Provincial Nursing Skin and Wound Committee, 2014). Health care providers should recognize MDT is not simply a form of wound care dressing. Because it is a biological method of wound debridement, cost of MDT should be compared with surgical debridement rather than conventional dressings.

Evidence-based standards of care and policies should be initiated to guide implementation of MDT. They should include selection of appropriate patients as candidates for MDT, preparation of wounds for MDT, involvement of wound care nurses, education of clinical nursing staff, patients' informed consent, patient and family education, and guidelines for safe and effective implementation of MDT as debridement therapy. Standards should be articulated clearly to identify possible candidates for MDT. Wound care nurses may direct maggot debridement therapy after having training in this technique; clinical nurses should be responsible for maintaining therapy and providing emotional support, pain management, and education related to the intervention. Informed consent likely will be required for MDT (British Columbia Provincial Nursing Skin and Wound Committee, 2014).

Patient selection, preparation, and treatment should be managed meticulously. Because pressure on the MDT dressing may kill the maggots, only patients with wounds that can be protected from all pressure would be candidates for MDT. In addition, MDT should not be the sole therapy for wounds infected with Pseudomonas aeruginosa or wounds involving bones or tendons. Patients who may benefit from MDT include those with pressure ulcers, diabetic skin ulcers, traumatic wounds, vascular deficiency wounds (arterial and venous), burns, and wounds colonized with resistant microorganisms, especially if patients are poor candidates for traditional surgical debridement (British Columbia Provincial Nursing Skin and Wound Committee, 2014).

Preparation for MDT as debridement should include optimization of the wound. Patient nutritional status, hydration, perfusion, and pain intensity should be addressed to optimize wound healing after effective debridement. The wound should be cleaned of all dried exudate and eschar before application of medical-grade maggots. Maggots must be applied sterilely using a flap or tea-bag application to avoid maggot escape. If one or more maggots appear to have escaped, the bedding must be removed and a terminal cleaning of the room must be accomplished (British Columbia Provincial Nursing Skin and Wound Committee, 2014).

During implementation of MDT, nurses should monitor the dressing as well as patient pain intensity. The dressing should be assessed for drainage and changed as needed. Dressings must be air- and moisture-permeable to ensure survival of the maggots, so drainage should be expected. Pain management is a concern due to the maggots' debriding activity, so nurses should assess pain frequently and manage pain through appropriate nursing interventions. Based on pain intensity and health care provider order, nurses may administer nonsteroidal anti-inflammatory drugs or opioids. Nerve blocks may be needed in some cases (British Columbia Provincial Nursing Skin and Wound Committee, 2014). Patients and family members need emotional support and education to adhere to the MDT treatment plan. This care continues throughout the implementation of MDT.

Future research on MDT should identify best ways to manage pain during therapy and analyze cost of therapy. Qualitative research should explore the impact of maggot debridement on patients, family members, and nursing staff. Research has not identified the best way to prevent maggot escape, other than to use the tea bag application method, so studies should explore the most clinically effective, cost-effective application method and the optimal length of time for MDT usage in patient care.

Conclusion

Maggot debridement therapy is an ancient treatment being brought into modern times. As antibiotic resistance grows, the medical community is struggling to find an effective treatment to help heal chronic wounds. MDT is a viable alternative to traditional debridement and should be considered as an option by health care providers. EED

REFERENCES

British Columbia Provincial Nursing Skin and Wound Committee. (2014). Guideline: Maggot debridement therapy (MDT) in adults and children. Retrieved from https://www.clwk.ca/buddydrive/file/guide line-maggot-debridement-therapy/?down load=235%25253guideline-maggotdebridement-therapy-june-2012

Cazander, G., Schreurs, M.W., Renwarin, L., Dorresteijn, C., Hamann, D., & Jukema, G.N. (2012). Maggot excretions affect the human complement system. Wound Repair and Regeneration, 20(6) 879886. doi: 10.1111/j.1524-475X.2012.008 50.x

Cazander, G., Pritchard, D.I., Nigam, Y., Jung, R., & Nibbering, P.H. (2013). Multiple actions of Lucilia sericata larvae in hard to heal wounds. Bioessays, 35, 10831092.

Heitkamp, R.A., Peck, G.W., & Kirkup, B.C. (2012). Maggot debridement therapy in modern army medicine: Perceptions and prevalence. Military Medicine, 177,14111416. doi:10.7205/MILMED-D-12-00200

Jones, J., Green, J., & Lille, A.K. (2011). Maggots and their role in wound care. British Journal of Community Nursing, 16(3), 24-33.

Margolin, L., & Gialanella, P. (2010). Assessment of the antimicrobial properties of maggots. International Wound Journal, 7(3), 202-204.

Mumcuoglu, K.Y., Davidson, E., Avidan, A., & Gilead, L. (2012). Pain related to maggot debridement therapy. Journal of Wound Care, 21(8), 400-405.

Paul, A.G., Ahmad, N.W., Lee, H.L., Ariff, A.M., Saranum, M., Naicker, A.S., & Osman, Z. (2009). Maggot debridement therapy with Lucilia cuprina: A comparison with conventional debridement in diabetic foot ulcers. International Wound Journal, 6(1), 39-46.

Pettican, A., & Baptista, C. (2012). Maggot debridement therapy and its role in chronic wound management. Singapore Nursing Journal, 39(1), 27-33.

Rafter, L. (2013). Using larval therapy in the community setting. Wound Care, 18(12), S20-25.

Sherman, R.A. (2002). Maggot versus conservative debridement therapy for the treatment of pressure ulcers. Wound Repair and Regeneration, 10(4), 208-214.

Soares, M.O., Iglesias, C.P., Bland, M., Cullum, N., Dumville, J.C., Nelson, E.A., ... Worthy, G. (2009). Cost effectiveness analysis of larval therapy for leg ulcers. British Medical Journal, 338, b825. doi :10.1136/bmjb825

Steenvoorde, P, Buddingh, T.J., Engeland, A., & Oskam, J. (2005). Maggot therapy and the 'yuk" factor: An issue for the patient? Wound Repair and Regeneration, 13(3), 350-352.

ADDITIONAL READINGS

Cazander, G., Pawiroredjo, J.S., Vandenbroucke-Grauls, C.M., Schreurs, M.W., & Jukema, G.N. (2010). Synergism between maggot excretions and antibiotics. Wound Repair and Regeneration, 18(6), 637-642. doi :10.1111/j.1524 475X.2010.00625.x

Gilead, L., Mumcuoglu, K.Y., & Ingber, A. (2012). The use of maggot debridement therapy in the treatment of chronic wounds in hospitalized and ambulatory patients. Journal of Wound Care, 21(2), 78-85.

Opletalova, K., Blaizot, X., Mourgeon, B., Chene, Y., Creveuil, C., Combemale, ... Dompmartin, A. (2012). Maggot therapy for wound debridement: A randomized multicenter trial. Archives of Dermatology, 148(A), 432-438.

Pritchard, D.I., & Nigam, Y. (2013). Maximising the secondary beneficial effects of larval debridement therapy. Journal of Wound Care, 22(11), 610-616.

Sherman, R.A. (2014). Mechanisms of maggot-induced wound healing: What do we know, and where do we go from here? Evidence-Based Complementary and Alternative Medicine [Epub], doi:10. 1155/2014/592419

Tian, X., Liang, X.M., Song, G.M., Zhao, Y., & Yang, X.L. (2013). Maggot debridement therapy for the treatment of diabetic foot ulcers: A meta-analysis. Journal of Wound Care, 22(9), 462-469.

Brian Bowman, MSN, RN, AGACNP-BC, is Nurse Practitioner, Dr. Kin C. Wong Pulmonary/Internal Medicine, Glendale, CA.

Alison Forbes, MSN, RN, ACNP-BC, is Acute Care Nurse Practitioner, Trauma/Surgery Department, Mission Hospital, Orange County, CA.

Kelsey Klaus, BSN, RN, is Registered Nurse, Haven Health, Santa Monica, CA.

Cynthia Steinwedel, PhD, RN, CNE, is Assistant Professor, Department of Nursing, Bradley University, Peoria, IL; and a MEDSURG Nursing Editorial Board Member.
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Title Annotation:Research for Practice
Author:Klaus, Kelsey; Steinwedel, Cynthia
Publication:MedSurg Nursing
Article Type:Report
Date:Nov 1, 2015
Words:3652
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