Degradation of extracellular matrix components by defined proteinases from the greenbottle larva Lucilia sericata used for the clinical debridement of non-healing wounds

Pain Assessment in Patients Undergoing Maggot Debridement Therapy in the Process of Local Treatment of Chronic Wounds

(1) Background: Developing and implementing strategies for local wound care focused on improving the quality of life related to health status and reducing treatment costs for this patient group poses a challenge to contemporary healthcare systems. The utilization of Maggot Debridement Therapy (MDT) is one potential form of local therapy for preparing wounds for the healing process. The debridement of the wound bed with medical maggots is highly precise, and the defensins produced by the larvae eliminate bacteria and stimulate tissue regeneration. However, the presence of larvae in the wound may lead to the occurrence of pain symptoms. The aim of the study was to assess the intensity of pain during larval therapy in patients with chronic wounds treated in outpatient settings. (2) Patients and Methods: The study employed a diagnostic survey and estimation; the tool consisted of a research protocol comprising three parts (questionnaires). Inclusion criteria for the study were voluntary consent to participate (completion of the MDT acceptance questionnaire), chronic wounds of vascular etiology or pressure injuries, full-thickness skin or deep tissue damage, and pain intensity not exceeding four on the NRS (Numerical Rating Scale: 0-no pain, 10-the most severe pain) at the time of the study. Patient observation during the 3-day treatment was conducted by a wound care clinic nurse, assessing pain intensity once every 24 h during the larval dressing changes. (3) Results: Out of 348 individuals who qualified for MDT during the study period, 215 individuals participated in the study: 94 women (43.7%) and 121 men (56.3%). The age of the participants ranged from 28 to 97 years (mean 69.87 ± 12.95). Each participant experienced mild pain (2.26 ± 1.60 on the NRS) on the day of qualification for the study. An increase in pain intensity, according to subjective assessments, was reported by 29.3% of participants (n = 63). On the third day of MDT therapy, an increase in pain intensity was observed, reaching a mean value of 4.79 ± 2.12 (p < 0.0001). Participants with pressure injuries showed the lowest pain intensity, which increased in consecutive days for all types of wounds. Additionally, the increase in pain intensity in patients with vascular etiology wounds was greater compared to patients with pressure injuries (p < 0.001). (4) Conclusions: Local wound therapy with Lucilia sericata larvae increases pain intensity in the consecutive days of treatment. The wound area and the time since its occurrence may determine pain symptoms.

Cloning, expression and molecular analysis of recombinant Netrin-A protein of Lucilia sericata Meigen (Diptera: Calliphoridae) larvae

Objectives

Lucilia sericata (Diptera: Calliphoridae) is used in larval therapy for wound healing. Netrin-A is an enzyme secreted from the salivary glands of these larvae, and has a central role in neural regeneration and angiogenesis. This study aimed to produce the recombinant Netrin-A protein from Lucilia sericata larvae by the baculovirus expression vector system in the Sf9 insect cell line.

Methods

The coding sequence of Netrin-A was cloned, amplified in the pTG19 vector, and then cloned in the pFastBac HTA vector. It was then transformed into DH10Bac, and the recombinant Bacmid was subsequently transfected into Sf9 cells. The recombinant Netrin-A was purified by Ni-NTA agarose. The evaluation was done using SDS-PAGE and western blot, respectively. Finally, its concentration was calculated with the Bradford assay.

Results

The molecular weight of this protein was 52 kDa with 404 amino acids. The signal peptide was located between amino acids 24 and 25. The concentration of Netrin-A was calculated to be 48.8 μg/ml. It reaffirmed the characterized gene codes of Lucilia sericata Netrin-A in a previous study.

Conclusions

The generation of recombinant Netrin-A could be used in larval therapy, and as a biomarker in certain diseases. The netrin-A of Lucilia sericata was unprecedentedly cloned and expressed in a eukaryotic cell line. Given that this larva is FDA-approved, and non-pathogenic, it conduces to research on the development of maggot therapy in future.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

How Rearing Systems for Various Species of Flies Benefit Humanity

Flies (Diptera) have played a prominent role in human history, and several fly species are reared at different scales and for different beneficial purposes worldwide. Here, we review the historical importance of fly rearing as a foundation for insect rearing science and technology and synthesize information on the uses and rearing diets of more than 50 fly species in the families Asilidae, Calliphoridae, Coelopidae, Drosophilidae, Ephydridae, Muscidae, Sarcophagidae, Stratiomyidae, Syrphidae, Tachinidae, Tephritidae, and Tipulidae. We report more than 10 uses and applications of reared flies to the well-being and progress of humanity. We focus on the fields of animal feed and human food products, pest control and pollination services, medical wound therapy treatments, criminal investigations, and on the development of several branches of biology using flies as model organisms. We highlight the relevance of laboratory-reared Drosophila melanogaster Meigen as a vehicle of great scientific discoveries that have shaped our understanding of many biological systems, including the genetic basis of heredity and of terrible diseases such as cancer. We point out key areas of fly-rearing research such as nutrition, physiology, anatomy/morphology, genetics, genetic pest management, cryopreservation, and ecology. We conclude that fly rearing is an activity with great benefits for human well-being and should be promoted for future advancement in diverse and innovative methods of improving existing and emerging problems to humanity.

Anti-inflammatory and wound healing potential of medicinal maggot excretions/secretions at the ocular surface

PURPOSE

In the skin, Lucilia sericata maggot excretions/secretions (ES) accelerate wound healing and limit inflammation. This study aimed to determine whether ES have similar beneficial effects at the ocular surface.

METHODS

Human corneal epithelial cells (HCEC) were cultured with ES and cell viability was determined by the MTT assay. Additionally, mRNA expression of growth factors, antimicrobial peptides (AMPs) and cytokines was assessed by qPCR. ES ability to modulate TLR-induced IL-6 and IL-8 expression was determined by qPCR and ELISA. ES potential to promote corneal healing was evaluated in vitro by a migration assay in HCEC, and in vivo using a mouse model.

RESULTS

ES did not impair HCEC viability up to 25 μg/ml. Among the factors evaluated, only hBD-2 was upregulated (2.5-fold) by 1.5 μg/ml ES after 6 hrs (P = 0.04). In HCEC, ES reduced Poly I:C-induced IL-6 and IL-8 mRNA (P ≤ 0.001) and protein (P ≤ 0.0001) expression. A similar effect was observed with Flagellin (TLR5 agonist) but it was less robust for FSL-1 (TLR2/6 agonist) and Pam3CSK4 (TLR1/2 agonist). The greatest in vitro migration effect was observed with 6.2 μg/ml ES after 44 hrs where gap area compared to vehicle was 53.3 ± 3.7% vs. 72.6 ± 5.4% (P = 0.001). In the mouse model, the maximum healing effect was present with 1.5 μg/ml ES after 12 hrs with a wound area of 19.0 ± 2.7% vs. 60.1 ± 21.6% (P = 0.003) or 77% reduction of the wound area compared to the negative control.

CONCLUSIONS

ES significantly reduce in vitro TLR-induced production of inflammatory cytokines and promote corneal wound healing.

Identification, molecular characterization, and in silico structural analysis of larval salivary glands Netrin-A as a potent biomarker from Lucilia sericata (Diptera: Calliphoridae)

The greenbottle blowfly Lucilia sericata (L. sericata) is increasingly used in larval therapy of chronic wounds. Netrins as bifunctional proteins are in the superfamily of Laminins secreted from larval salivary glands. The Netrin protein has a significant instructive role in axon guidance, causing neuronal outgrowth, angiogenesis, and cell migration. It seems to be crucial in wound healing and acts as a potential biomarker in diagnosing some clinical diseases. This survey aimed to identify molecular features and analyze in silico structural configuration of Netrin-A in L. sericata larvae. The larvae were reared under standard maggotarium conditions. The nucleic acid sequence of L. sericata Netrin-A (LSN-A) was then identified using rapid amplification of circular DNA ends (RACE) and rapid amplification of genomic ends (RAGE). Parts of the Netrin-A gene, including the middle, 3'-, and 5'-ends, were identified, TA cloned in pTG19 plasmid, and transferred into DH5ɑ Escherichia coli. Each part was sequenced and assembled using SeqMan software. This gene structure was further subjected to in silico analysis. The DNA of LSN-A was identified to be 2407 bp, while its mRNA sequence was recognized as 2115 bp by Oligo0.7 software. It translated the Netrin-A protein with 704 amino acid residues. Its estimated molecular weight was 78.6 kDa. Sequencing of this fragment and its BLAST analysis revealed laminin-based high (95%) similarity with the mRNA sequence of Lucilia cuprina Netrin-A. The 3-D structure of Netrin-A drawn by SWISS-MODEL exhibited its partial resemblance to the reference molecule Netrin-1 of Homo sapiens. This study supports the molecular and structural analyses of LSN-A protein, which could lead to wound treatment. Ultimately, it can be an effective candidate to ameliorate injury. Our next attempt is to produce LSN-A recombinant protein for use in biomedical sciences.

Therapeutic effects of Lucilia sericata larval excretion/secretion products on Leishmania major under in vitro and in vivo conditions

Background

Leishmaniasis is a neglected infectious disease caused by protozoa of the genus Leishmania. The disease generally manifests as characteristic skin lesions which require lengthy treatment with antimonial drugs that are often associated with adverse side effects. Therefore, a number of studies have focused on natural compounds as promising drugs for its treatment. This study aimed to evaluate the effects of larval excretion/secretion products (ES) of Lucilia sericata in crude and fractionated forms on Leishmania major, by using in vitro and in vivo models.

Methods

The in vitro experiments involved evaluation of ES on both promastigotes and macrophage-engulfed amastigotes, whereas the in vivo experiments included comparative treatments of skin lesions in L. major-infected mice with Eucerin-formulated ES and Glucantime.

Results

The half maximal inhibitory concentrations of the crude ES, > 10-kDa ES fraction, < 10-kDa ES fraction, and Glucantime were 38.7 μg/ml, 47.6 μg/ml, 63.3 μg/ml, and 29.1 μg/ml, respectively. Significant differences were observed between percentage viabilities of promastigotes treated with the crude ES and its fractions compared with the negative control (P < 0.0001). The crude ES was more effective on amastigotes than the two ES fractions at 300 μg/ml. The macroscopic measurements revealed that the reduction of lesion size in mice treated with the crude ES followed quicker cascades of healing than that of mice treated with Glucantime and the ES fractions.

Conclusions

The present study showed that the larval ES of L. sericata in both crude and fractionated forms are effective for both intracellular and extracellular forms of L. major. Also, the ES exert both topical and systemic effects on mice experimentally infected with L. major.

Graphical abstract

Maggot debridement therapy to treat hard-to-heal diabetic foot ulcers: a single-centre study

OBJECTIVE

Maggot debridement therapy (MDT) has seen a resurgence in recent years in the treatment of hard-to-heal wounds, as a result of rising antibiotic resistance. The sterilised larvae of Lucilia cuprina have been used in MDT in Malaysia since 2003, with encouraging results for the treatment of hard-to-heal diabetic wounds. We report a case series of 30 patients selected from our clinic by convenient sampling with diabetic lower limb ulcers treated with MDT. The average age of patients receiving MDT was >50 years. Of the 30 patients in the study, nine were female and 21 were male. All patients had underlying diabetes, two patients had leg ulcers and 28 patients had diabetic foot ulcers. Sterilised Lucilia cuprina larvae were applied via a standard method of 10 maggots per square centimetre and dressed with sterile gauze. The study endpoint was defined as ≤5% coverage with slough or necrotic tissue following three successive applications of MDT. In this study, maximum debridement of wounds was achieved in 96.6% (29 patients) of our patients, with ≤5% coverage with slough or necrotic tissue, in addition to a reduction in wound-related pain, as assessed by a visual analogue scale. No adverse events were reported. The findings of this study support the use of MDT as a safe, efficacious, and cost-effective method of managing diabetic wounds.

Maggot Debridement Therapy for Chronic Leg and Foot Ulcers: A Review of Randomized Controlled Trials

OBJECTIVE

To critically analyze the existing randomized controlled trials (RCTs) on the clinical, economic, and psychological implications of maggot debridement therapy (MDT).

DATA SOURCES

An exhaustive literature search for English-language publications was conducted using MEDLINE, EMBASE, and PubMed.

STUDY SELECTION

Keywords used for the search were based on the PICO (Population, Intervention, Comparison, Outcome) framework. The titles, abstracts, and relevant full-text articles were screened. Seven RCTs were selected after applying the inclusion and exclusion criteria.

DATA EXTRACTION

Data pertaining to the primary and secondary outcomes of each study were extracted.

DATA SYNTHESIS

The data extracted were evaluated and categorized into clinical, economic, and psychological outcomes pertaining to MDT. A judicious evaluation of these outcomes was made, and the following conclusions were drawn.

CONCLUSIONS

There exists heterogeneity in the extant RCTs, but MDT appears to be effective for a quick early debridement. For diabetic foot ulcers, MDT improves debridement, controls infection, and enhances wound healing. In chronic peripheral vascular disease ulcers, it aids in early debridement, but the final outcome is equivocal. Further robust integrated health economic and parallel qualitative assessment studies are recommended to understand the cost-effectiveness and patient acceptability and experience.

Wound healing and antibacterial activities of water-soluble chitosan nanoparticles and excretion/secretion as a natural combination from medicinal maggots, Lucilia cuprina

Wounds management takes a high interest in the medical field and the addition of antimicrobial agents in an assortment of wound dressings leads to delay the wound healing. This study aimed at preparing natural combination between excretion/secretion (ES) and water-soluble chitosan nanoparticles (from Lucilia cuprina maggots) and investigating its antibacterial and wound healing activities. ES of maggots was collected, and the water-soluble chitosan nanoparticles (WSCNPs) were prepared and characterized. Antibacterial activities of combinations were evaluated against Staphylococcus aureus, Bacillus subtilis, Escherichia coli, and Proteus vulgaris. ES-WSC-2 combination that contains 50% ES and 1% WSCNPs showed highest antibacterial activity against all tested bacteria compared to the other combinations. In vitro, the ES-WSC-2 combination was used to study the wound healing activity by scratch assay. The synergism between ES and WSCNPs (in ES-WSC-2 combination) accelerated the wound healing rate which suggests the use of this combination as an effective natural antibacterial and wound healing agent.

Genome and transcriptome sequencing of the green bottle fly, Lucilia sericata, reveals underlying factors of sheep flystrike and maggot debridement therapy

The common green bottle blow fly Lucilia sericata (family, Calliphoridae) is widely used for maggot debridement therapy, which involves the application of sterile maggots to wounds. The larval excretions and secretions are important for consuming necrotic tissue and inhibiting bacterial growth in wounds of patients. Lucilia sericata is also of importance as a pest of sheep and in forensic studies to estimate a postmortem interval. Here we report the assembly of a 565.3 Mb genome from long read PacBio DNA sequencing of genomic DNA. The genome contains 14,704 predicted protein coding genes and 1709 non-coding genes. Targeted annotation and transcriptional analyses identified genes that are highly expressed in the larval salivary glands (secretions) and Malpighian tubules (excretions) under normal growth conditions and following heat stress. The genomic resources will underpin future genetic studies and in development of engineered strains for genetic control of L. sericata and for biotechnology-enhanced maggot therapy.

The effect of Lucilia sericata larval excretion/secretion (ES) products on cellular responses in wound healing

Chronic wounds are still regarded as a serious public health concern, which are on the increase mainly due to the changes in life styles and aging of the human population. There are different types of chronic wounds, each of which requires slightly different treatment strategies. Nevertheless, wound bed preparation is included in treatment of all types of chronic wounds and involves tissue debridement, inflammation, and infection control, as well as moisture balance and epithelial edge advancement. Maggot therapy (MT) is a form of biological debridement which involves the application of live medical grade Lucilia sericata (Meigen, 1826) (Diptera: Calliphoridae) larvae. Whereas it was initially thought to act mainly through debridement, today MT is known to influence all four overlapping physiological phases of wound repair: homeostasis, inflammation, proliferation, and remodelling/maturing. During MT, medical-grade larvae are applied either freely or enclosed in tea-bag like devices (biobag) inside the wounds, which suggests that larva excretion/secretion (ES) products can facilitate the healing processes directly without the need of direct contact with the larvae. This review summarizes the relevant literature on ES-mediated effects on the cellular responses involved in wound healing.

A molecular approach to maggot debridement therapy with Lucilia sericata and its excretions/secretions in wound healing

Chronic wounds caused by underlying physiological causes such as diabetic wounds, pressure ulcers, venous leg ulcers and infected wounds affect a significant portion of the population. In order to treat chronic wounds, a strong debridement, removal of necrotic tissue, elimination of infection and stimulation of granulation tissue are required. Maggot debridement therapy (MDT), which is an alternative treatment method based on history, has been used quite widely. MDT is an efficient, simple, cost-effective and reliable biosurgery method using mostly larvae of Lucilia sericata fly species. Larvae can both physically remove necrotic tissue from the wound site and stimulate wound healing by activating molecular processes in the wound area through the enzymes they secrete. The larvae can stimulate wound healing by activating molecular processes in the wound area through enzymes in their excretions/secretions (ES). Studies have shown that ES has antibacterial, antifungal, anti-inflammatory, angiogenic, proliferative, hemostatic and tissue-regenerating effects both in vivo and in vitro. It is suggested that these effects stimulate wound healing and accelerate wound healing by initiating a direct signal cascade with cells in the wound area. However, the enzymes and peptides in ES are mostly still undefined. Examining the molecular content of ES and the biological effects of these ingredients is quite important to illuminate the molecular mechanism underlying MDT. More importantly, ES has the potential to have positive effects on wound healing and to be used more as a therapeutic agent in the future, so it can be applied as an alternative to MDT in wound healing.

Efficacy of maggot debridement therapy on refractory leg ulcers of Behçet disease: an open-label study

BACKGROUND

Cutaneous ulcers of Behçet disease (BD) are rare but have high morbidity and resistance to conventional therapies. An important and essential aspect of ulcer management is debridement. Regarding maggot therapy (MT), excretions of the green bottle fly, Lucilia sericata, have been shown to have the ability to remove necrotic debris and promote healing.

AIM

To evaluate the efficacy of MT for cutaneous ulcers of BD.

METHODS

In this open-label trial, patients with BD with refractory leg ulcers suitable for MT were enrolled. Maggot application was performed until complete debridement was achieved, and all patients were followed up for 12 months afterwards to assess the total healing of ulcers.

RESULTS

In total, 24 patients with 32 ulcers were enrolled. Using MT, 91.6% of all ulcers were completely debrided. Mean time to debridement was 14.9 days and mean number of cycles required was 5.3. Mean ulcer size was decreased by 23% with treatment. Time to debridement was positively correlated with pretreatment ulcer size and ulcer duration (P = 0.01 and P < 0.01) but not with ulcer depth, comorbidities, smoking, age or sex (P > 0.05 for all). During follow-up, 79.1% of all ulcers healed completely. Mean time required for total healing was positively correlated with ulcer duration, pretreatment and post-treatment ulcer area, ulcer depth and mean time to total debridement (P < 0.03, P = 0.00, P = 0.04 and P < 0.01, respectively).

CONCLUSIONS

To our knowledge, the findings presented in this first and unique study may provide key answers about factors affecting success rate of MT in BD cutaneous ulcers.

Evaluation of Larval Therapy Compared to Antibiotic Therapy in the Treatment of Skin Wounds in Rabbits

Larval therapy (LT) is a therapeutic modality that uses larvae of necrophagous flies for the treatment of wounds. The use of this therapy presents several benefits, due to the action of the larvae that remove necrotic tissue selectively, exercising antimicrobial action, and promoting healing. There are situations in which LT proves to be the only or the best alternative for the patient, such as wounds infected by multidrug-resistant microorganisms or when treatment difficulties may lead to an indication for amputation. The purpose of this study was to compare the efficiency of LT, using larvae of Chrysomya megacephala, with that of antibiotic therapy in the treatment of cutaneous wounds infected with Pseudomonas aeruginosa. Twenty-four rabbits were used to perform the experiment, distributed in four groups: group 1, induced wound without bacterial infection; group 2, induced wound with bacterial infection; group 3, induced wound with bacterial infection and antibiotic therapy; group 4, induced wound with bacterial infection and LT. The macroscopic, microscopic, and statistical analyses indicated that LT was as effective as antibiotic therapy in wound healing.

The leishmanicidal effect of Lucilia sericata larval saliva and hemolymph on in vitro Leishmania tropica

Background

Leishmaniasis is a major parasitic disease worldwide, except in Australia and Antarctica, and it poses a significant public health problem. Due to the absence of safe and effective vaccines and drugs, researchers have begun an extensive search for new drugs. The aim of the current study was to investigate the in vitro leishmanicidal activity of larval saliva and hemolymph of Lucilia sericata on Leishmania tropica.

Methods

The effects of different concentrations of larval products on promastigotes and intracellular amastigotes of L. tropica were investigated using the mouse cell line J774A.1 and peritoneal macrophages as host cells. The 3-(4.5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and direct observation and counting method were used to assess the inhibitory effects and cell cytotoxicity of the larval products. The effects of larval products on the amastigote form of L. tropica were quantitatively estimated by calculating the rate of macrophage infection, number of amastigotes per infected macrophage cell, parasite load and survival index.

Results

The 50% cytotoxicity concentration (CC₅₀) value of both larval saliva and hemolymph was 750 µg/ml, and the 50% inhibitory concentration (IC₅₀) values were 134 µg/ml and 60 µg/ml for larval saliva and larval hemolymph, respectively. The IC₅₀ for Glucantime, used a positive control, was (11.65 µg/ml). Statistically significant differences in viability percentages of promastigotes were observed for different doses of both larval saliva and hemolymph when compared with the negative control (p ≤ 0.0001). Microscopic evaluation of the amastigote forms revealed that treatment with 150 µg/ml larval hemolymph and 450 µg/ml larval saliva significantly decreased the rate of macrophage infection and the number of amastigotes per infected macrophage cell.

Conclusion

Larval saliva and hemolymph of L. sericata have acceptable leishmanicidal properties against L. tropica.

Graphical Abstract

Aural Myiasis: A Case Report and Literature Review

Myiasis is a type of parasitosis caused by the larvae of diptera. It commonly occurs in tropical and subtropical zones. The infestation of nose and ears can be extremely dangerous if the larvae destroy the bone and penetrate into the brain, in which case the fatality rate is reported to be as high as 8%. Here, we report a case of aural myiasis in a patient with congenital mental retardation. Twelve maggots were removed mechanically, and the patient was treated with appropriate antibiotics.

Crustacean Proteases and Their Application in Debridement

Digestive proteases from marine organisms have been poorly applied to biomedicine. Exceptions are trypsin and other digestive proteases from a few cold-adapted or temperate fish and crustacean species. These enzymes are more efficient than enzymes from microorganism and higher vertebrates that have been used traditionally. However, the biomedical potential of digestive proteases from warm environment species has received less research attention. This review aims to provide an overview of this unrealised biomedical potential, using the debridement application as a paradigm. Debridement is intended to remove nonviable, necrotic and contaminated tissue, as well as fibrin clots, and is a key step in wound treatment. We discuss the physiological role of enzymes in wound healing, the use of exogenous enzymes in debridement, and the limitations of cold-adapted enzymes such as their poor thermal stability. We show that digestive proteases from tropical crustaceans may have advantages over their cold-adapted counterparts for this and similar uses. Differences in thermal stability, auto-proteolytic stability, and susceptibility to proteinase inhibitors are discussed. Furthermore, it is proposed that the feeding behaviour of the source organism may direct the evaluation of enzymes for particular applications, as digestive proteases have evolved to fill a wide variety of feeding habitats, natural substrates, and environmental conditions. We encourage more research on the biomedical application of digestive enzymes from tropical marine crustaceans.

Practical context of enzymatic treatment for wound healing: A secreted protease approach (Review)

Skin wounds have been extensively studied as their healing represents a critical step towards achieving homeostasis following a traumatic event. Dependent on the severity of the damage, wounds are categorized as either acute or chronic. To date, chronic wounds have the highest economic impact as long term increases wound care costs. Chronic wounds affect 6.5 million patients in the United States with an annual estimated expense of $25 billion for the health care system. Among wound treatment categories, active wound care represents the fastest-growing category due to its specific actions and lower costs. Within this category, proteases from various sources have been used as successful agents in debridement wound care. The wound healing process is predominantly mediated by matrix metalloproteinases (MMPs) that, when dysregulated, result in defective wound healing. Therapeutic activity has been described for animal secretions including fish epithelial mucus, maggot secretory products and snake venom, which contain secreted proteases (SPs). No further alternatives for use, sources or types of proteases used for wound healing have been found in the literature to date. Through the present review, the context of enzymatic wound care alternatives will be discussed. In addition, substrate homology of SPs and human MMPs will be compared and contrasted. The purpose of these discussions is to identify and propose the stages of wound healing in which SPs may be used as therapeutic agents to improve the wound healing process.

Maggot Debridement Therapy in Malaysia

Maggot therapy, also known as maggot debridement therapy, larval therapy, biodebridement, or biosurgery, is a type of biotherapy involving the intentional application of live, disinfected fly larvae or maggots into the nonhealing wound of a human or animal to debride the necrotic wound, reduce bacterial contamination of the wound as well as enhance the formation of healthy granulation tissue and stimulate healing in nonhealing wounds. In addition, van der Plas et al reported that the use of the medicinal larvae as natural remover of necrotic and infected tissue had prevented amputation in 11 selected patients. In Malaysia, Aaron et al had demonstrated prevention of amputation in 25 patients.

A Survey on Inhibitory Effect of Whole-Body Extraction and Secretions of Lucilia sericata's Larvae on Leishmania major In vitro

Background:

Leishmaniasis is a skin disease caused by Leishmania parasite. Despite being self-limiting, must be treated. Available drugs have side effects and drug resistance has also been seen.

Materials and Methods:

Maggot debridement therapy (MDT) is using sterile fly larvae (maggots) of blow flies (Lucilia sericata) for the treatment of different types of tissue wounds. Larvae have excreted and secreted substances that have been proved to have antimicrobial effects, in addition to the some other specifications.

Results:

In this study, the anti-leishmanial effects of extracts and secretions of sterile second- and third-instar larvae of L. sericata on the growth of Leishmania major promastigotes and amastigotes in the J774 macrophages have been evaluated in vitro.

Conclusion:

The results showed that extracts and secretions had almost the same leishmaniocidal effect on promastigotes and intracellular amastigotes without cytotoxic effect on macrophages.

New Insights Into Culturable and Unculturable Bacteria Across the Life History of Medicinal Maggots Lucilia sericata (Meigen) (Diptera: Calliphoridae)

Because of the nutritional ecology of dung- and carrion-feeding, bacteria are the integral part of Lucilia sericata life cycle. Nevertheless, the disinfected larvae of the blowfly are applied to treat human chronic wounds in a biosurgery named maggot debridement therapy (MDT). To realize the effects of location/diet on the gut bacteria, to infer the role of bacteria in the blowfly ecology plus in the MDT process, and to disclose bacteria circulating horizontally in and vertically between generations, bacterial communities associated with L. sericata specimens from various sources were investigated using culture-based and culture-independent methods. In total, 265 bacteria, including 20 families, 28 genera, and 40 species, were identified in many sources of the L. sericata. Culture-dependent method identified a number of 144 bacterial isolates, including 21 species, in flies reared in an insectary; specimens were collected from the field, and third-instar larvae retrieved from chronic wounds of patients. Metagenetic approach exposed the occurrences of 121 operational taxonomic units comprising of 32 bacterial species from immature and adult stages of L. sericata. Gammaproteobacteria was distinguished as the dominant class of bacteria by both methods. Bacteria came into the life cycle of L. sericata over the foods and transovarially infected eggs. Enterococcus faecalis, Myroides phaeus, Proteus species, Providencia vermicola, and Serratia marcescens were exchanged among individuals via transstadial transmission. Factors, including diets, feeding status, identification tool, gut compartment, and life stage, governed the bacteria species. Herein, we reemphasized that L. sericata is thoroughly connected to the bacteria both in numerous gut compartments and in different life stages. Among all, transstadially transmitted bacteria are underlined, indicating the lack of antagonistic effect of the larval excretions/secretions on these resident bacteria. While the culture-dependent method generated useful data on the viable aerobic gut bacteria, metagenomic method enabled us to identify bacteria directly from the tissues without any need for cultivation and to facilitate the identification of anaerobic and unculturable bacteria. These findings are planned to pave the way for further research to determine the role of each bacterial species/strain in the insect ecology, as well as in antimicrobial, antibiofilm, anti-inflammatory, and wound healing activities.

Antiviral and virucidal activities of Lucilia cuprina maggots' excretion/secretion (Diptera: Calliphoridae): first work

Maggots of Lucilia sericata and L. cuprina are a backbone of the maggot debridement therapy. Further, the excretion/secretion (E/S) of these maggots has antibacterial and antifungal activities, nevertheless the antiviral activity of E/S for these maggots still out the focus. This study aimed to evaluate the E/S of L. cuprina maggots against the Rift Valley Fever (RVF) and Coxsackie B4 (CB4) viruses for first time. After collection of the E/S, its cytotoxicity on Vero cells was evaluated and the safe concentration was determined which used to investigate the antiviral and virucidal effect of E/S on the selected viruses. The E/S decreased the titers of the tested viruses compared with that of untreated viruses. The outcome data refer to that the E/S of L. cuprina consider as a promising antiviral and virucidal agent.

Effectiveness of Chronic Wound Debridement with the Use of Larvae of Lucilia Sericata

The process of successful wound healing depends on effective debridement and infection control. One method of wound debridement, known since antiquity, is based on the use of fly larvae. Solid scientific evidence proves that maggot debridement therapy (MDT), like surgical intervention, can be effectively and safely used to remove necrotic tissue. Based on a review of the related literature, this study was designed to assess the effectiveness of chronic wound cleansing with the use of larvae of Lucilia sericata (Phaenicia sericata). Maggot therapy, applied in wound debridement and treatment, is a safe and effective method. Its benefits are associated with debridement, disinfection and faster tissue growth. MDT may reduce the duration of antibiotic therapy and the need for hospitalization, or it may decrease the number of outpatient visits required. It is a relatively cost-effective method, and, in addition to financial gains, it may reduce the frequency of inpatient treatment. In the literature, an increasing amount of scientific evidence confirms that such treatment can effectively reduce the biofilm and bacterial load in a wound.

Bactericidal Activity of Chrysomya rufifacies and Cochliomyia macellaria (Diptera: Calliphoridae) Larval Excretions-Secretions Against Staphylococcus aureus (Bacillales: Staphylococcaceae)

The inhibitory effect of Chrysomya rufifacies (Macquart) and Cochliomyia macellaria (Fabricius) larval excretions-secretions (ES) on Staphylococcus aureus was determined using a portable colorimetric method without the need for any dedicated spectral instrument. Polystyrene 96 well microplates were used and 100 μl of the bacterial inoculum (5 × 105 CFU/ml) plus 100 μl of the dipteran exosecretions at different concentrations were added to each well. Subsequently, 50 μl of a 1% solution of the triphenyl tetrazolium chloride stain was added to each well to determine the bacterial viability. The color development in each well was measured with the ImageJ software S. aureus was exposed to different concentrations of the ES of both species individually. At a concentration of 800 ppm ES of C. rufifacies or Co. macellaria, bacterial growth was inhibited 97.45 ± 1.70% and 82.21 ± 1.88%, respectively. As expected, exposure to a lower concentration (i.e., 50 ppm) was less inhibitory (C. rufifacies ES, 77.65 ± 4.25% and Co. macellaria ES, 43.54 ± 4.63%). This study demonstrates for the first time the bactericidal activity of C. rufifacies and Co. macellaria ES against S. aureus. This finding is promising as it could result in the identification and synthesis of proteins capable of suppressing pathogen development in wounds. Additionally, the proposed method can simplify the use of expensive laboratory instruments for antimicrobial activity determination.

Embryonic mesothelial-derived hepatic lineage of quiescent and heterogenous scar-orchestrating cells defined but suppressed by WT1

Activated hepatic stellate cells (aHSCs) orchestrate scarring during liver injury, with putative quiescent precursor mesodermal derivation. Here we use lineage-tracing from development, through adult homoeostasis, to fibrosis, to define morphologically and transcriptionally discreet subpopulations of aHSCs by expression of WT1, a transcription factor controlling morphological transitions in organogenesis and adult homoeostasis. Two distinct populations of aHSCs express WT1 after injury, and both re-engage a transcriptional signature reflecting embryonic mesothelial origin of their discreet quiescent adult precursor. WT1-deletion enhances fibrogenesis after injury, through upregulated Wnt-signalling and modulation of genes central to matrix persistence in aHSCs, and augmentation of myofibroblastic transition. The mesothelial-derived lineage demonstrates punctuated phenotypic plasticity through bidirectional mesothelial-mesenchymal transitions. Our findings demonstrate functional heterogeneity of adult scar-orchestrating cells that can be whole-life traced back through specific quiescent adult precursors to differential origin in development, and define WT1 as a paradoxical regulator of aHSCs induced by injury but suppressing scarring.

Non-antibiotic antimicrobial interventions and antimicrobial stewardship in wound care

Control of wound infection today relies largely on antibiotics, but the continual emergence of antibiotic-resistant microorganisms threatens a return to the pre-antibiotic era when physicians used antiseptics to prevent and manage infection. Some of those antiseptics are still used today, and others have become available. A diverse variety of non-antibiotic antimicrobial interventions are found on modern formularies. Unlike the mode of action of antibiotics, which affect specific cellular target sites of pathogens, many non-antibiotic antimicrobials affect multiple cellular target sites in a non-specific way. Although this reduces the likelihood of selecting for resistant strains of microorganisms, some have emerged and cross-resistance between antibiotics and antiseptics has been detected. With the prospect of a post-antibiotic era looming, ways to maintain and extend our antimicrobial armamentarium must be found. In this narrative review, current and emerging non-antibiotic antimicrobial strategies will be considered and the need for antimicrobial stewardship in wound care will be explained.

Effective wound bed preparation using maggot debridement therapy for patients with critical limb ischaemia

OBJECTIVE

Patients with critical limb ischaemia (CLI) lack sufficient blood flow in to the limb, which leads to difficulties in the normal wound healing process. Therefore, maggot debridement therapy (MDT) has not generally been recommended for CLI patients. We evaluated the effectiveness of wound bed preparation by MDT in CLI patients who had undergone mid-foot amputation.

METHODS

Patients who underwent mid-foot amputation after angioplasty between April 2014 and October 2016 were retrospectively investigated by classifying them into an MDT group or a conventional treatment group. The primary outcome was defined as achievement of wound healing. Secondary outcomes were the proportions of amputation-free survival (AFS) and successful ambulatory improvement. Propensity scores were used to evaluate treatment outcomes based on five factors: ankle-brachial index, skin perfusion pressure of the foot, nutritional status, experience with dialysis and age.

RESULTS

A total of 39 patients (39 legs) were included, seven within the MDT group and 32 in the conventional treatment group. Clinical backgrounds of the two groups showed no significant differences except for higher albumin levels for the MDT group (3.5±0.4g/dl; p=0.014). The wound healing proportion was significantly higher in the MDT group (86%) than in the control group (38%) (p=0.035). At 6 months after amputation, no significant differences were found between the two groups for AFS (71% versus 47%; p=0.41) or ambulatory capability (43% versus 28%; p=0.65). This result was also similar to the propensity score adjustment analysis.

CONCLUSIONS

The efficacy of MDT with favourable wound bed preparation was shown in our CLI patients based on effective debridement and granulation formation by maggots, avoiding the loss of their heels. Wound-healing rates after MDT were higher for patients than for those receiving conventional treatment. MDT is considered a valid adjuvant treatment strategy for patients with CLI after revascularisation treatment is conducted. More favourable wound bed preparation and successful graft take were achieved in the MDT group, suggesting the effectiveness of MDT for wound healing in CLI patients.

Facing death together: heterospecific aggregations of blowfly larvae evince mutual benefits

Heterospecific aggregations and foraging associations have been observed between different species, from apes to birds to insects. Such associations are hypothesized to result in a mutually beneficial relationship entailing benefits that are not apparent in conspecific groupings. Therefore, the objectives of the present study were to investigate 1) how 3 blowfly species, namely, Calliphora vicina, Calliphora vomitoria, and Lucilia sericata, aggregate according to species, and 2) if developmental benefits are linked to heterospecific aggregation. For objective (1), larvae of 2 species were placed between 2 conspecific aggregates, each with a different species (i.e., a binary choice test). After 20 h, the positions of all larvae were determined. On average, 98% of the maggots added later settled together on one of the 2 pre-existing aggregations, demonstrating a collective choice. The aggregation spot with C. vicina was preferred against others, indicating different attractiveness of different species. To relate this behavior to its benefits (objective ii), C. vicina and L. sericata larvae were raised from first instar to adult in con- and heterospecific conditions, and their development time, mortality rates, and morphometrics were measured. Thereby, mutual and asymmetric consequences were observed: specifically, there were significant increases in size and survival for L. sericata and faster development for C. vicina in heterospecific groups. These results indicate that the predilection for heterospecific association leads to mutual developmental benefits. This heterospecific aggregation behavior may be a resource-management strategy of blowflies to face carrion-based selection pressure.

Collagenolytic Enzymes and their Applications in Biomedicine

Nowadays, enzymatic therapy is a very promising line of treatment for many different diseases. There is a group of disorders and conditions, caused by fibrotic and scar processes and associated with the excessive accumulation of collagen that needs to be catabolized to normalize the connective tissue content. The human body normally synthesizes special extracellular enzymes, matrix metalloproteases (MMPs) by itself. These enzymes can cleave components of extracellular matrix (ECM) and different types of collagen and thus maintain the balance of the connective tissue components. MMPs are multifunctional enzymes and are involved in a variety of organism processes. However, under pathological conditions, the function of MMPs is not sufficient, and these enzymes fail to deal with disease. Thus, medical intervention is required. Enzymatic therapy is a very effective way of treating such collagen-associated conditions. It involves the application of exogenous collagenolytic enzymes that catabolize excessive collagen at the affected site and lead to the successful elimination of disease. Such collagenolytic enzymes are synthesized by many organisms: bacteria, animals (especially marine organisms), plants and fungi. The most studied and commercially available are collagenases from Clostridium histolyticum and from the pancreas of the crab Paralithodes camtschatica, due to their ability to effectively hydrolyse human collagen without affecting other tissues, and their wide pH ranges of collagenolytic activity. In the present review, we summarize not only the data concerning existing collagenase-based medications and their applications in different collagen-related diseases and conditions, but we also propose collagenases from different sources for their potential application in enzymatic therapy.

On the Cutting Edge: Wound Care for the Endovascular Specialist

Clinical outcomes in patients with critical limb ischemia (CLI) depend not only on endovascular restoration of macrovascular blood flow but also on aggressive periprocedural wound care. Education about this area of CLI therapy is essential not only to maximize the benefits of endovascular therapy but also to facilitate participation in the multidisciplinary care crucial to attaining limb salvage. In this article, we review the advances in wound care products and therapies that have granted the wound care specialist the ability to heal previously nonhealing wounds. We provide a primer on the basic science behind wound healing and the pathogenesis of ischemic wounds, familiarize the reader with methods of tissue viability assessment, and provide an overview of wound debridement techniques, dressings, hyperbaric therapy, and tissue offloading devices. Lastly, we explore emerging technology on the horizons of wound care.

Coumarin Reduces Virulence and Biofilm Formation in Pseudomonas aeruginosa by Affecting Quorum Sensing, Type III Secretion and C-di-GMP Levels

As one of the major pathogens in wound infections, Pseudomonas aeruginosa produces several virulence factors and forms biofilms; these processes are under the regulation of various quorum sensing (QS) systems. Therefore, QS has been regarded as a promising target to treat P. aeruginosa infections. In the present study, we evaluated the effect of the plant-derived QS inhibitor coumarin on P. aeruginosa biofilms and virulence. Coumarin inhibited QS in the P. aeruginosa QSIS2 biosensor strain, reduced protease and pyocyanin production, and inhibited biofilm formation in microtiter plates in different P. aeruginosa strains. The effects of coumarin in inhibiting biofilm formation in an in vitro wound model and reducing P. aeruginosa virulence in the Lucilia sericata infection model were strain-dependent. Transcriptome analysis revealed that several key genes involved in the las, rhl, Pseudomonas quinolone signal (PQS), and integrated QS (IQS) systems were downregulated in coumarin-treated biofilms of P. aeruginosa PAO1. Coumarin also changed the expression of genes related to type III secretion and cyclic diguanylate (c-di-GMP) metabolism. The cellular c-di-GMP level of P. aeruginosa PAO1 and recent clinical P. aeruginosa strains was significantly reduced by coumarin. These results provide new evidence for the possible application of coumarin as an anti-biofilm and anti-virulence agent against P. aeruginosa in wound infections.

[Research progress of chronic wound debridement]

Objective

To review the research progress of chronic wound debridement.

Methods

The recent related literature concerning the mechanisms, advantages, limitations, and indications of the technologies of chronic wound debridement was extensively consulted, reviewed, and summarized.

Results

Debridement is essential for chronic wound healing, which includes autolytic debridement, enzymatic debridement, biodebridement, mechanical debridement, sharp/surgical debridement, ultrasound debridement, hydrosurgery debridement, and coblation debridement. Each technique has its own advantages and disadvantages.

Conclusion

There are many types of technologies of chronic wound debridement, which can be chosen according to clinical conditions. It is showed there are more significant advantages associated with the technique of coblation debridement relatively, which also has greater potential. Further study is needed to improve its efficacy.

Pharmacological Properties of the Medical Maggot: A Novel Therapy Overview

In the last decade, maggot has been hailed as the miraculous “medicinal maggot” for its diverse properties, including antimicrobial, antibiofilm, anti-inflammatory, and wound healing activities. The fact that maggots show so many beneficial properties has increased the interest in these tiny larvae dramatically. Whilst there is relatively abundant clinical evidence to demonstrate the success of maggots as debridement agents, not so much emphasis has been placed on the basic science evidence, which was a combination of physical and biochemical actions. This review differs from those earlier works in that it is undertaken to provide an update of the latest scientific basis published on maggot, particularly active ingredients within maggot excretions/secretions (ES). Further investigations should focus on the isolation, identification, recombination, transgenosis, and mass production of the beneficial molecules within maggots.

The transcriptional responses of cultured wound cells to the excretions and secretions of medicinal Lucilia sericata larvae

Maggots, through their excretions and secretions (ES), promote wound healing by removing necrotic tissue, counter bacterial infection, and activate wound associated cells. We investigated the effects of a physiological dose of maggot ES on four wound-associated cell types in vitro with Affymetrix gene expression arrays; keratinocytes, endothelial cells, fibroblasts, and monocytes. Keratinocytes showed the fewest (n = 5; p < 0.05, fold-change ±2) and smallest fold-changes (up to 2.32×) in gene expression and conversely THP1 monocytes had the most (n = 233) and greatest magnitude (up to 44.3×). There were no genes that were altered in all four cell-lines. Gene pathway analysis identified an enrichment of immune response pathways in three of the treated cell-lines. Analyses by quantitative RT-PCR found many genes dynamically expressed in ES dose dependent manner during the three day treatments. Phenotype analyses, however, found no effects of ES on cell viability, proliferation, migration and angiogenesis. ES was 100× less potent at triggering IL-8 secretion than fibroblasts treated with purified bacterial lipopolysaccharide (LPS; in equivalent amounts to that found in ES; ∼40 EU/ml). Furthermore, co-treatment with LPS and ES decreased the LPS-alone triggered IL-8 secretion by 13%. Although ES had no direct effect on wound cell phenotypes it did partially reduce the immune response to bacterial LPS exposure. These observations were consistent with the profile of transcriptional responses that were dominated by modulation of immune response genes. Maggot therapy may therefore improve wound healing through the secondary effects of these gene changes in the wound cells.

Disruption of Staphylococcus Epidermidis Biofilms by Medicinal Maggot Lucilia Sericata Excretions/Secretions

Chronic infections are commonly associated with biofilms formed by bacteria such as Staphylococcus epidermidis. With the increase in antibiotic resistant bacteria, maggot debridement therapy has been reintroduced for the treatment of chronic wounds. Studies have shown that the excretion/secretions (ES) of Lucilia sericata larvae (maggots) contain many bioactive compounds which may contribute to the efficacy of maggot therapy. The present study evaluates the effect of L. sericata ES on the formation and disruption of S. epidermidis 7457 and 5179-R1 biofilms. These strains employ either polysaccharide intercellular adhesin (PIA) or accumulation associated protein (Aap) for intercellular adhesion.

A semiquantitative biofilm assay was used to measure the formation/disruption of S. epidermidis 7457 and 5179-R1 biofilms by ES. ES activity was characterized according to concentration, incubation time and temperature, thermal stability, and size. Immunofluorescence microscopy was used to ascertain the effect of ES on PIA and Aap.

In the presence of ES, S. epidermidis 7457 and 5179-R1 nascent bio film formation was inhibited, and pre-formed biofilms disrupted. ES activity was temperature and time dependent, inactivated by heat treatment, and disruption depended on the mechanism of intercellular adhesion. The molecule(s) responsible was >10 kDa in size and appeared to have protease or glucosaminidase activity.

ES interferes with S. epidermidis biofilm formation, specifically degrading factors employed in biofilm accumulation, which would increase bacterial susceptibility to antibiotics and the host's immune system. In purified form, ES-factors may have general applicability for the treatment or prevention of chronic biofilm infections caused by staphylococci.

Evaluating the anti-leishmania activity of Lucilia sericata and Sarconesiopsis magellanica blowfly larval excretions/secretions in an in vitro model

Leishmaniasis is a vector-borne disease caused by infection by parasites from the genus Leishmania. Clinical manifestations can be visceral or cutaneous, the latter mainly being chronic ulcers. This work was aimed at evaluating Calliphoridae Lucilia sericata- and Sarconesiopsis magellanica-derived larval excretions and secretions' (ES) in vitro anti-leishmanial activity against Leishmania panamensis. Different larval-ES concentrations from both blowfly species were tested against either L. panamensis promastigotes or intracellular amastigotes using U937-macrophages as host cells. The Alamar Blue method was used for assessing parasite half maximal inhibitory concentration (IC₅₀) and macrophage cytotoxicity (LC₅₀). The effect of larval-ES on L. panamensis intracellular parasite forms was evaluated by calculating the percentage of infected macrophages, parasite load and toxicity. L. sericata-derived larval-ES L. panamensis macrophage LC₅₀ was 72.57μg/mL (65.35-80.58μg/mL) and promastigote IC₅₀ was 41.44μg/mL (38.57-44.52μg/mL), compared to 34.93μg/mL (31.65-38.55μg/mL) LC₅₀ and 23.42μg/mL (22.48-24.39μg/mL) IC₅₀ for S. magellanica. Microscope evaluation of intracellular parasite forms showed that treatment with 10μg/mL L. sericata ES and 5μg/mL S. magellanica ES led to a decrease in the percentage of infected macrophages and the amount of intracellular amastigotes. This study produced in vitro evidence of the antileishmanial activity of larval ES from both blowfly species on different parasitic stages and showed that the parasite was more susceptible to the ES than it's host cells. The antileishmanial effect on L. panamensis was more evident from S. magellanica ES.

Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics

OBJECTIVE

The aim is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to treat and eradicate infection in patients with tibial pilon or calcaneal fractures.

METHODS

Eleven consecutive patients with dehiscence of the surgical wound in outcomes MIPO using a Locking Compression Plate (LCP) for tibial pilon, or calcaneus fractures. The patients had developed a documented infection of the surgical wound. All patients were treated and followed-up by the multidisciplinary team with the orthopedic surgeon, the plastic surgeon and the infectious disease physician. All patients were followed by the plastic surgeon to treat the wound dehiscence, as well as by the orthopedic surgeon until fracture consolidation. The duration of the antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. The follow-up intervals were 15 days, 40 days, and 3 months.

RESULTS

The average time of wound closure was 109±60 days. The antibiotics used were chosen according to the antibiogram. The antibiotic therapy had a duration of 4-6 months, and after 6 weeks, the therapy switched to oral administration. At the 3-month follow-up, all patients had excellent outcomes and had returned to their normal activity of daily living.

CONCLUSION

The patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisplinary treatment in association with titanium devices are able to eradicate infection in short time.

Benefits of maggot debridement therapy on leg ulcers: a literature review

Maggot debridement therapy (MDT) is an effective method for debriding wounds such as leg ulcers, supporting the concept of wound bed preparation ( Dumville et al, 2009 ; Soares et al, 2009 ; Mudge et al, 2014 ). New evidence is emerging to suggest that maggots might contribute to wound healing in other ways. For example, the reduction of biofilms and disinfection of wounds ( Van Der Plas et al, 2008 ; Brown et al, 2012 ; Pritchard and Brown, 2015 ) plus regulation of protease levels ( Chambers et al, 2003 ; Van Der Plas et al, 2009a ; Van Der Plas et al, 2009b ). This review will discuss research exploring new benefits of maggots in the management of individuals with chronic leg ulcers.

Evaluation of blowfly larvae (Diptera: Calliphoridae) as possible reservoirs and mechanical vectors of African swine fever virus

In 2014, highly virulent African swine fever virus (ASFV) was introduced into the Baltic States and Poland, with new cases being reported almost every week from wild boar and also from domestic pigs. Contrary to initial predictions that the disease would either die out due to the high virulence of the virus strain or spread rapidly in westerly direction, the infection became endemic and spread slowly. The unexpected disease epidemiology led to the hypothesis that hitherto unconsidered factors might contribute to virus persistence and dispersal. To check whether arthropod species feeding and developing on infected carcasses might be involved, larvae of two commonly found blowfly species, Lucilia sericata and Calliphora vicina, were experimentally bred on ASFV-infected spleen tissue. After different time intervals, developing larvae and pupae were tested for infectious virus and viral DNA. By qPCR, contamination of the blowfly larvae and pupae with ASFV-DNA could be demonstrated even after several washing steps, proving the uptake of virus during feeding in the larval stage. However, infectious virus could never be isolated. By contrast, the larvae appeared to have inactivated ASFV in the offered tissue, which might be explained by the known anti-biotic effect of salivary secretions. It is concluded that immature blowfly stages do not play a relevant role as reservoirs or mechanical vectors of ASFV.

Quality control of a medicinal larval (Lucilia sericata) debridement device based on released gelatinase activity

Lucilia sericata Meigen (Diptera: Calliphoridae) larvae are manufactured worldwide for the treatment of chronic wounds. Published research has confirmed that the primary clinical effect of the product, debridement (the degradation of non-viable wound tissue), is accomplished by a range of enzymes released by larvae during feeding. The quality assessment of larval activity is currently achieved during production using meat-based assays, which monitor insect growth and/or the reduction in substrate mass. To support this, the present authors developed a complementary radial diffusion enzymatic assay to produce a visual and measureable indication of the activity of larval alimentary products (LAP) collected under standardized conditions, against a gelatin substrate. Using basic laboratory equipment and reagents, the assay is rapid and suited to high throughput. Assay reproducibility is high (standard deviation: 0.06-0.27; coefficient of variation: 0.75-4.31%) and the LAP collection procedure does not adversely affect larval survival (mortality: < 2%). Because it is both cost- and time-effective, this method is suited to both academic and industrial use and supports good manufacturing and laboratory practice as a quality control assay.

Maggot debridement therapy for a patient with critical limb ischaemia and severe cardiac dysfunction: possibility of limb salvage

Ischaemic skin ulcer occurred on the foot of a 73-year-old man who had a history of fulminant myocarditis with severe cardiac dysfunction. We attempted wound bed preparation by maggot debridement therapy and salvaged his limb. It can be one of the adjuvant treatment strategies for critical limb ischaemia.

Endotoxin testing of a wound debridement device containing medicinal Lucilia sericata larvae

Alimentary products of medicinal Lucilia sericata larvae are studied to determine their mechanisms of action, particularly in the contexts of wound debridement and disinfection. Furthermore, the larvae can be applied to patients in contained medical devices (such as the BioBag; BioMonde). Here, we tested the materials and larval content of the most commonly used debridement device (the "BB-50") to explore the possibility that endotoxins may be contributing to the bio-activity of the product, given that endotoxins are potent stimulants of cellular activation. Using standardised protocols to collect larval alimentary products (LAP), we proceeded to determine residual endotoxin levels in LAP derived from the device, before and after the neutralisation of interfering enzymatic activity. The debridement device and its associated larval content was not a significant source of lipopolysaccharide (LPS) activity. However, it is clear from these experiments that a failure to remove the confounding serine proteinase activity would have resulted in spuriously high and erroneous results. The residual LPS levels detected are unlikely to be active in wound healing assays, following cross-referencing to publications where LPS at much higher levels has been shown to have positive and negative effects on processes associated with wound repair and tissue regeneration.

Targeting microbial biofilms using Ficin, a nonspecific plant protease

Biofilms, the communities of surface-attached bacteria embedded into extracellular matrix, are ubiquitous microbial consortia securing the effective resistance of constituent cells to environmental impacts and host immune responses. Biofilm-embedded bacteria are generally inaccessible for antimicrobials, therefore the disruption of biofilm matrix is the potent approach to eradicate microbial biofilms. We demonstrate here the destruction of Staphylococcus aureus and Staphylococcus epidermidis biofilms with Ficin, a nonspecific plant protease. The biofilm thickness decreased two-fold after 24 hours treatment with Ficin at 10 μg/ml and six-fold at 1000 μg/ml concentration. We confirmed the successful destruction of biofilm structures and the significant decrease of non-specific bacterial adhesion to the surfaces after Ficin treatment using confocal laser scanning and atomic force microscopy. Importantly, Ficin treatment enhanced the effects of antibiotics on biofilms-embedded cells via disruption of biofilm matrices. Pre-treatment with Ficin (1000 μg/ml) considerably reduced the concentrations of ciprofloxacin and bezalkonium chloride required to suppress the viable Staphylococci by 3 orders of magnitude. We also demonstrated that Ficin is not cytotoxic towards human breast adenocarcinoma cells (MCF7) and dog adipose derived stem cells. Overall, Ficin is a potent tool for staphylococcal biofilm treatment and fabrication of novel antimicrobial therapeutics for medical and veterinary applications.