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Maggot therapy is also known as maggot debridement therapy (MDT), larval therapy, larva therapy, larvae therapy, bio debridement or bio surgery.

Maggot therapy is essentially a controlled therapeutic myiasis (maggot infestation on a live host). It is controlled by selecting a safe and effective species and strain via quality control measures throughout the breeding and manufacturing processes. The species used for medicinal purposes are chemically disinfected to produce a germ free maggot, and when used in therapy are contained within a special dressing that prevents them from leaving the wound unescorted. The maggots cleared by the FDA in 2004 for marketing in the United States belong to the LB-01 strain of Phaenicia Lucilia sericata. Phaenicia sericata (blow fly) larvae are harvested and provide disinfection for use in debriding non-healing necrotic skin and soft tissue wounds, including pressure ulcers, venous stasis ulcers, neuropathic foot ulcers, and non-healing traumatic or post surgical wounds.

Note that not all species are safe and effective for wound treatment, however this strain has been widely and successfully used and is safe as they only consume the non-viable tissues, leaving the viable tissues untouched.

The maggots are applied to the wound at a dose of 5-10 larvae per square centimeter of wound surface area and are left within the wound dressing for 48-72 hours. After this time the larvae are satiated, finished with their work and can be removed.

History

Maggots: An ancient remedy

Ancient cultures throughout the world have successfully used maggots (fly larvae) to cleanse suppurating and gangrenous wounds. The Mayan Indians of Central America used to ceremoniously wrap wounds with dressings made of sun-exposed beef blood that would pulsate with larvae a few days after they were applied.. The Ngemba aboriginal tribe of New South Wales, Australia, have also used maggot therapy for thousands of years.. During World War II, the Burmese Hill People were observed placing maggots on wounds and covering them with mud and wet grass.. The Old Testament is the oldest known document to site myiasis, in which humans are infested with maggots. It described Job who complained, "My body is clothed with worms and scabs, my skin is broken and festering."

However, the first medical reference to maggots appeared in the Hortus Sanitatis, one of the earliest European medical texts, published in 1491.

Natures Best surgeons at work during the wars

Ambroise Pare (1509-1590), the chief surgeon to Charles IX and Henri III was the first to observe the beneficial effects of fly larvae on the suppurating wounds of soldiers on the balllefield of St. Quentin 1557. He observed a wounded soldier with a deep penetrating skull wound filled with a "great number of worms...from underneath the putrefied skull" and he noticed that the "patient recovered beyond all men's expectation."

The first official documented therapeutic application of maggots took place during the American Civil War (1861-1965). Dr. John Zacharies (1837-1901), a confederate surgeon, reported that, "I used maggots to remove the decayed tissue in hospital gangrene and with eminent satisfaction. Maggots in a single day would clean a wound much better than any agent we had at our command. I am sure I have saved many lives by their use".

However, if was not until Dr. William S. Baer (1872-1931) also noted the beneficial effects of myiasis in wounds on the battle field in France during World War I that the therapeutic use of maggots gained popularity.. He observed two soldiers with serious compound fractures of the femur that presented without septicemia at a time where the mortality rate for compound fractures of femurs was around 75-80%. "On removing the clothing from the wounded part, much was my surprise to see the wound filled with thousands and thousands of maggots, apparently those of the blow fly...instead of having a wound filled with pus, as one would have expected...these wounds were filled with the most beautiful pink granulation tissue."

Other military physicians also observed soldiers whose wounds had become colonized with maggots, experienced significantly less morbidity and mortality than soldier without maggot colonization. These physicians included Napoleon’s general surgeon, Baron Dominique Larrey. Larrey reported during France's Egyptian campaign in Syria, 1798–1801, that certain species of fly consumed only dead tissue and helped wounds to heal.

Dr. Joseph Jones, a ranking Confederate medical officer during the American Civil War, is quoted as follows, "I have frequently seen neglected wounds ... filled with maggots ... as far as my experience extends, these worms eat only dead tissues, and do not injure specifically the well parts."

Case studies and modern use

While at Johns Hopkins University in 1929, Dr. Baer introduced maggots into 21 patients with intractable chronic osteomyelitis. He observed rapid debridement, reductions in the number of pathogenic organisms, reduced odor levels, alkalinization of wound beds, and ideal rates of healing. All 21 patients' open lesions were completely healed and they were released from the hospital after two months of maggot therapy.

After the publication of Dr. Baer's results in 1931, maggot therapy for wound care became very common, particularly in the United States. The Lederle pharmaceutical company commercially produced "Surgical Maggots", larvae of the green bottle fly, which primarily feed on the necrotic (dead) tissue of the living host without attacking living tissue. Between 1930 and 1940, more than 100 medical papers were published on maggot therapy. Medical literature of this time contains many references to the successful use of maggots in chronic or infected wounds including osteomyelitis, abscesses, burns, sub-acute mastoiditis, and chronic empyema.

More than three hundred American hospitals employed maggot therapy during the 1940s. The extensive use of maggot therapy prior to World War II was curtailed when the discovery and growing use of penicillin caused it to be deemed outdated. Due to the lack of conventional medicines, maggot therapy was used by Allied military medical staff in Japanese prisoner of war camps in the Far East throughout World War II.

Discover magazine reported in 1993 how the country physician Grady A. Dugas of Union Parish, Louisiana, had used maggots to cure the bedsores of an 80-year-old male patient. Some of the sores were nearly an inch deep, and infection had set in. Conventional therapies, including antibiotics and surgery, had failed. Dugas told the magazine that he remembered his grandmother, who was diabetic, had undergone successful maggot treatment in the 1930s. He followed suit, and the man's sore healed within a month. Instead of facing amputation, the patient instead went into the hospital for skin grafts.

Reintroduction – more case studies

With the advent of antibiotic-resistant bacteria, Dr. Ronald Sherman, a physician previously at the University of California, Irvine, sought to re-introduce maggot therapy into the armamentarium of modern medical care. In 1989, he set up fly breeding facilities at the Veterans Affairs Medical Center in Long Beach, California in order to use maggots for the treatment of wounds. Using a Paralyzed Veterans of America grant, he initiated a prospective controlled clinical trial of maggot therapy for spinal cord patients with pressure ulcers who had failed two or more courses of conventional wound care.

Over 50 scientific papers have been published that describe the medical use of maggots. Six thousand maggot therapy patients have been included in case histories or other studies. About 400 patients have been documented within clinical studies, most of them are included in a British study financed by the NHS.

Limb salvage rates with maggot therapy are about 40% to 50% according to the medical literature. Some report success rates of 70% to 80%, though definitions of "success" can vary.

In a 2007 preliminary trial, maggots were used successfully to treat patients whose wounds were infected with MRSA, a bacterium (Staphylococcus aureus) with resistance to most antibiotics, including methicillin. Some of these strains include flesh eating bacteria causing frequent deaths upon infection of deep tissue. Maggots clean up the already dead tissue thus preventing further infection spread.

In 1995, a handful of doctors in four countries were using maggot therapy. Today, any physician in the U.S. can prescribe maggot therapy. There are over 800 health care centers in the United States that have utilized maggot therapy. Over 4,000 therapists are using maggot therapy in 20 countries. Approximately 50,000 treatments were applied to wounds in the year 2006. These data appear on the website of the Wound Care Information Network, but the original sources are not provided.

Regulation

In January 2004, the U.S. Food and Drug Administration (FDA) granted permission to produce and market maggots for use in humans or animals as a prescription-only medical device for the following indications: "For debriding non-healing necrotic skin and soft tissue wounds, including pressure ulcers, venous stasis ulcers, neuropathic foot ulcers, and non-healing traumatic or post-surgical wounds." In February 2004, the British National Health Service (NHS) permitted its doctors to prescribe maggot therapy. In the European Union, Canada and Japan, maggots are classified as medicinal drugs, needing a full market licence. In the U.S., maggots for medicinal use are classified as a device.

Veterinary use

The use of maggots to clean dead tissue from animal wounds is part of folk medicine in many parts of the world. It is particularly helpful with chronic osteomyelitis, chronic ulcers, and other pus-producing infections that are frequently caused by chafing due to work equipment. Maggot therapy for horses in the United States was re-introduced after a study published in 2003 by veterinarian Dr. Scott Morrison. This therapy is used in horses for conditions such as osteomyelitis secondary to laminitis, sub-solar abscesses leading to osteomyelitis, post-surgical treatment of street-nail procedure for puncture wounds infecting the navicular bursa, canker, non-healing ulcers on the frog, and post-surgical site cleaning for keratoma removal.

However, there have not been many case studies done with maggot debridement therapy on animals, therefore, it can be difficult to assess how successful it is (Jones & Wall, 2007).

Application of maggot wound dressings

Maggots are contained in a cage-like dressing over the wound for two days. The maggots may be allowed to move freely within that cage, with the wound floor acting as the bottom of the cage; or the maggots may be contained within a sealed pouch, placed on top of the wound. The dressing must be kept air permeable because maggots need oxygen to live. When maggots are satiated, they become substantially larger and seek to leave the site of a wound to find somewhere suitable to pupate. Multiple two-day courses of maggot therapy may be administered depending on the severity of the non-healing wound.

Maggots can never reproduce in the wound since they are still in the larval stage and too immature to reproduce. They can only reproduce when they become adult flies and mate.

Mechanisms of action

The maggots have 4 principal actions reported in medical literature:

Medical studies have identified 4 major actions of medical maggots on wounds:

• Debridement
• Disinfection of the wound
• Stimulation of Healing
• Biofilm/Slough Inhibition and Eradication

Maggot therapy is further compatible with other wound care therapies such as antibiotics, negative pressure wound therapy (NPWT), skin grafting and hyperbaric oxygen therapy. While maggot therapy cannot be used simultaneously with NPWT, it can be used before NPWT to debride a wound so that it can be later closed with NPWT. Similarly, while maggot therapy cannot be used simultaneously with skin grafting, it can be used before skin grafting to debride a wound so that it can be later closed with skin grafting.

Debridement

In maggot therapy, large numbers of small maggots consume necrotic tissue far more precisely than is possible in a normal surgical operation, and can debride a wound in a day or two. Wound surface is typically increased with the use of maggots due to the surface wound not revealing the actual underlying size of the wound. They derive nutrients through a process known as "extracorporeal digestion" by secreting a broad spectrum of proteolytic enzymes that liquefy necrotic tissue, and absorb the semi-liquid result within a few days. In an optimum wound environment maggots molt twice, increasing in length from 1–2 mm to 8–10 mm, and in girth, within a period of 48-72 hours by ingesting necrotic tissue, leaving a clean wound free of necrotic tissue when they are removed.

Disinfection

Any wound infection is always a serious medical complication. Infected living tissue cannot heal. If the wound is infected with an antibiotic-resistant bacterial strain, it becomes difficult or impossible to treat the underlying infection and for any healing to occur. Wound infection could further be limb- and life-threatening. Maggot secretions are also effective against some antibiotic-resistant bacteria and have been shown to possess potent antimicrobial activity in early experimental studies from the 1930s. As early as 1957, a specific antibiotic factor was found in maggot secretions and published in the journal Nature. Secretions believed to have broad-spectrum antimicrobial activity include allantoin, urea, phenylacetic acid, phenylacetaldehyde, calcium carbonate, proteolytic enzymes, and many others. Bacteria not killed by these secretions are subsequently ingested and lysed within the maggots.

In vitro studies have shown that maggots inhibit and destroy a wide range of pathogenic bacteria including methicillin-resistant Staphylococcus aureus (MRSA), group A and B streptococci, and Gram-positive aerobic and anaerobic strains. Therefore maggot therapy might represent a cost-effective method for managing MRSA infection. Other bacteria like Pseudomonas aeruginosa, E.coli or Proteus spec are not attacked by maggots and in case of Pseudomonas even the maggots are in danger. Consequently, using maggots alone might lead to a change of bacteria cultures on the wound.

Wound healing

Maggot therapy has been expected from case studies to have wound healing properties, but the definitive advantage is still debated.

Limitations

The wound must be of a type which can actually benefit from the application of maggot therapy. A moist, exudating wound with sufficient oxygen supply is a prerequisite. Not all wound-types are suitable: wounds which are dry, or open wounds of body cavities do not provide a good environment for maggots to feed. In some cases it may be possible to make a dry wound suitable for larval therapy by moistening it with saline soaks, applied for 48 hours.

Maggots have a short shelf life which prevents long term storage before use. Patients and doctors may find maggots distasteful, although studies have shown that this does not cause patients to refuse the offer of maggot therapy. Maggots can be enclosed in opaque polymer bags to hide them from sight. Dressings must be designed to prevent any maggots from escaping, while allowing air to get to the maggots. Dressings are also designed to minimize the uncomfortable tickling sensation that the maggots often cause.

Comparative studies

In 2008, a scientific study published in the British Medical Journal compared the merits of maggot therapy and standard hydrogels to treat 270 British patients with leg ulcers from around the UK. Patients were treated with either maggots or hydrogel and their progress followed for up to a year.

The study revealed no significant differences in the time taken for the ulcer to heal, or in the patient's quality of life. Maggots were shown to be no more effective than hydrogel treatment at reducing the amount of bacteria present or in clearing MRSA. Although maggots were significantly more efficient at debridement of the wound, treatment with maggots was associated with more pain by patients. A separate study which compared the relative cost-effectiveness of maggot therapy with hydrogels estimated there was little to choose between the two therapies.

In a 2011 study of people with non-healing wounds, maggot therapy was more effective in debriding than conventional surgical wound-cleaning during the first week, but there was no significant added benefit by day 15. Surprisingly, wounds debrided by maggots showed significantly increased wound surface compared to surgical debridement "Moreover, the second week of treatment could be deleterious because a significant increase in wound surface area at day 15 in the MDT group was observed".

Biology of flies and maggots used in maggot therapy

Maggots are fly larvae, or immature flies, just as caterpillars are butterfly or moth larvae. Not all species of flies are safe and effective as medicinal maggots. There are thousands of species of flies, each with its own habits and life cycle. Some fly larvae feed on plants or animals, or even blood. Others feed on rotting organic material.

Those flies whose larvae feed on dead animals will sometimes lay their eggs on the dead parts (necrotic or gangrenous tissue) of living animals. The infestation by maggots of live animals is called "myiasis." Some maggots will feed only on dead tissue, some only on live tissue, and some on live or dead tissue. The flies used most often for the purpose of maggot therapy are "blow flies" (Calliphoridae); and the species used most commonly is Lucilia sericata, the common green bottle fly. Another important species, Protophormia terraenovae, is also notable for its feeding secretions, which combat infection by Streptococcus pyogenes and Streptococcus pneumoniae.

All maggots used for debridement are specialized and grown in a laboratory setting. This ensures that the larvae are sterilized in order to prevent secondary infections caused by microbes carried in by the maggots. Due to their short lifespan, usability is limited. This means that shipment must be direct and over night. They are also sensitive to temperature variations and must be transported with great care. Some of these challenges have limited the use of maggot therapy in certain regions of the world.

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External links

• National Geographic video segment on Maggot Medicine on youtube.com
• The NIH Record; Medieval Miracle Workers — Are Maggots Making a Medical Comeback? The National Institutes of Health experience with maggot therapy
• Wound Care Information Network write-up on everything you want to know about maggot therapy

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