Clinical study of Maggot therapy for Fournier's gangrene

Case series of maggot debridement therapy demonstrates safety and efficacy for treating problematic wounds in cats and dogs in Mexico

Wound care is a common problem in small animals. Antimicrobial resistance, biofilm, time constraints, and the cost of surgery or specialized dressings hinder efforts to deliver prompt wound healing. Maggot therapy has been very effective in human and equine wound care, but very little research has evaluated its safety and efficacy in dogs and cats. This study was initiated to evaluate the utility, efficacy, and safety of maggot debridement therapy for wound care in a small animal veterinary practice in Mexico. Six cats and four dogs were treated with maggot debridement therapy when their wounds failed to respond to conventional therapy. Treatment was administered by applying 8-10 larvae per cm2 surface area directly on the wound bed and covering the wound with a sterile polyester mesh, sutured to the skin. These were left on the wound for cycles of approximately 48 h (24-72 h); the cycles were repeated if >20 % necrotic tissue remained after treatment. Review of these cases revealed that 80 % of treated wounds achieved 100 % debridement within 48-96 h of treatment. An additional 10 % (one wound) achieved 80 % debridement within only 24 h of treatment. One animal failed to show improvement: a 3-year-old cat with an infected bite wound, which drained voluminously and drowned the maggots. This animal was deemed not to be an appropriate candidate for maggot debridement therapy, and treatment was terminated after just 12 h. Ultimately, this wound was debrided and closed surgically. No complications were encountered other than mild discomfort in one cat. These results support claims that maggot debridement therapy is relatively safe and effective for treating problematic dog and cat wounds. Veterinarians should consider including maggot debridement among their treatment options for problematic wounds. Controlled clinical trials should be performed.

Expanding access to maggot containment dressings through redesign and innovation

There are two major styles of maggot debridement dressings: (1) confinement dressings that form a cage around the wound, and (2) containment dressings that completely surround the maggots within a sealed porous bag. For producers and clinicians wanting to prepare containment dressings using readily available polyester bags, it is currently difficult to seal these bags without expensive high-temperature plastic welders. This study aimed to identify simple and affordable methods for sealing maggots within polyester net bags. Heat sealing was the most effective and simplest method to seal the polyester net bags, but the high melting point of polyester required industrial grade heat sealers. An inner lining of polyethylene or polypropylene film at the open side of the bag allowed for complete sealing using low-cost hand-actuated impulse heat sealers. This design even facilitated the addition of plastic zipper-locks, allowing secure closure of the bag without electricity or special equipment. Other sealing methods were identified, but most were time-consuming, required practice or not consistently successful. The maggot containment bag designs and closure methods described herein should prove useful to clinicians without access to contained maggots and to maggot producers without the resources to seal polyester containment bags. Clinical trials are expected to follow.

Not all maggots are created equal; not all maggots are therapeutic

Maggots in a wound ("myiasis") cannot be considered maggot therapy (therapeutic myiasis) unless, at a minimum, the species is known to be safe and effective, and the maggots have been properly disinfected. Documenting treatment details is critical and allows us to determine the cause of problems, if they arise.

Medical-Grade Honey Is a Versatile Wound Care Product for the Elderly

Introduction

Ageing of the global population has led to an increase in the demand for the treatment of wounds, especially considering the challenges of managing wounds in the elderly. Therefore, more effective treatment strategies need to be explored. In this article, we aimed to compare medical-grade honey (MGH) products with other wound care products and to provide guidelines on using MGH in wounds commonly found in the elderly.

Methods

Based on literature research and expert opinion, an overview of commonly used wound care products and their wound healing characteristics is provided. In addition, literature-based classification of wounds in the elderly and the recommendations for treatments are provided.

Results

Frequently used wound care products include povidone-iodine, enzymatic products, absorbing dressings, larvae, silver dressings, and MGH dressings. Supported by systematic reviews and meta-analyses, MGH dressings were identified as the most potent and all-round wound care product compared to the others. Next, we provided basic guidelines for managing the most common wounds in the elderly, both acute and chronic, and specified how and which MGH products can be used in these wounds.

Conclusion

MGH is a widely applicable, safe, easy-to-use, and cost-effective product to manage wounds in the elderly. In case of doubt, refer to a trained wound care specialist who can support the treatment of difficult-to-heal wounds.

Patient Perceptions and Experiences With Maggot Debridement Therapy for Managing Chronic Wounds

PURPOSE

The purpose of this study was to describe patient experiences and satisfaction with use of maggot debridement therapy (MDT) for hard-to-heal wounds.

DESIGN

Descriptive, cross-sectional study.

SUBJECTS AND SETTING

The sample comprised 60 participants, 60% were male (n = 36). Their mean age was 62.9 (SD = 20) years. Almost half of participants had lower extremity wounds (n = 26; 43.3%), diabetic foot ulcers (n = 18; 30%), and pressure injuries (n = 9; 15%). Most received maggot therapy via biobags (n = 36; 60%).

METHODS

Participants completed a questionnaire designed for purposes of the study that queried demographic and pertinent clinical characteristics, current health status including current topical therapies, and duration of their chronic wound. Nine items queried emotional responses prior to MDT, the amount and method of the maggot therapy, discomfort experienced during therapy, and sources of information regarding this treatment.

RESULTS

Emotional responses before starting MDT included disgust (n = 30, 50%), anxiety (n = 26, 43.3%), doubts about its effectiveness (n =20, 33.3%), and disbelief (n = 11, 18.3%). Approximately one-third of participants reported feelings of biting, itching, and fear of the maggots. Despite these feelings, a majority (n = 38, 63.3%) indicated that they were pleased with treatment outcome and willing to undergo additional MDT if needed.

CONCLUSIONS

While a majority of participants with nonhealing chronic wounds reported negative emotions association with MDT, more than half indicated that they were pleased with the outcome of treatment and willing to undergo repeat treatment if indicated.

A systematic review of efficacy on larva debridement in diabetic foot ulcers

Larva therapy, also known as maggot therapy, biodebridement, or maggot debridement therapy, involved the application of live fly larva to a patient’s wound for debridement, disinfection, and wound healing. Despite its wide application in diabetic foot ulcers, the efficacy of this intervention remains uncertain. This review aimed to examine the benefits of larva therapy in diabetic foot ulcers by conducting systematic review. This systematic review sought relevant articles using MeSH-based keywords in databases such as Scopus, PubMed, Science Direct, and ProQuest. The inclusion criteria for the articles were as follows: population - patients with diabetic foot ulcers, intervention - the use of debridement or therapeutic application of maggot therapy with Lucilia sericata, comparison - none, outcome - the results of articles demonstrating the effectiveness of using Lucilia sericata maggot therapy on diabetic foot ulcers. Article quality assessment was conducted using the Joanna Briggs Institute guidelines. Descriptive analysis was performed with a narrative approach, considering articles published from 2018 to 2023. Based on the literature search, 237 articles were found with matching keywords from Scopus (103), PubMed (77), Science Direct (14), and ProQuest (43). After screening for inclusion and exclusion criteria, 11 articles were identified for inclusion in this review. These 11 articles indicate that larva therapy can be an effective method in treating diabetic foot ulcers, especially when used correctly and tailored to each patient’s condition and needs. Green bottle fly larva, Lucilia sericata, produce proteolytic enzymes that can assist in wound healing. Larva therapy is effective when combined with other procedures. In clinical practice, it is highly recommended that nurses provide an individualized approach and assess potential side effects.

LARVOTERAPIA NO TRATAMENTO DE LESÕES DE DIFÍCIL CICATRIZAÇÃO: REVISÃO INTEGRATIVA

Objetivo:Analisar as evidências disponíveis na literatura acerca da utilização da larvoterapia no tratamento de feridas de difícil cicatrização. Método: Trata-se de revisão integrativa, tendo como questão norteadora: quais são as evidências disponíveis na literatura acerca da utilização da larvoterapia no tratamento de feridas de difícil cicatrização? Elegeram-se como critérios de inclusão: artigos originais, de revisão de literatura e de relatos de experiência, recorte temporal de 2016 a 2021, disponíveis online na íntegra, em português, inglês e espanhol e que respondessem à pergunta de pesquisa. Os critérios de exclusão foram: artigos duplicados, cartas ao editor, dissertações, teses, monografias e pesquisas com animais. Buscas ocorreram na Biblioteca Virtual em Saúde e Biblioteca Nacional de Medicina dos Estados Unidos entre agosto e setembro de 2021. Resultados: Selecionaram-se 10 artigos. As principais vantagens foram: desbridamento seletivo, ação bactericida ou bacteriostática e promoção de tecido de granulação e de fatores cicatrizantes. Já as principais desvantagens abrangeram: dor, desconforto, preconceito e fragilidades com o mercado de produção larval. Conclusão: As vantagens encontradas sobrepõem as desvantagens evidenciadas. Portanto, a larvoterapia é favorável para tratar feridas de difícil cicatrização.

LARVOTHERAPY IN THE TREATMENT OF DIFFICULT-TO-HEAL LESIONS: INTEGRATIVE REVIEW

Objective: To analyze the evidence available in the literature about the use of larvotherapy in the treatment of difficult-to-heal wounds. Method: This is an integrative review, having as a guiding question: what evidence is available in the literature about the use of larvotherapy in the treatment of wounds that are difficult to heal? The inclusion criteria were: original articles, literature review and experience reports, from 2016 to 2021, available online in full, in Portuguese, English and Spanish and that answered the research question. Exclusion criteria were: duplicate articles, letters to the editor, dissertations, theses, monographies and research with animals. Searches took place at Virtual Health Library and United Station National Library of Medicine between August and September 2021. Results: Ten articles were selected. The main advantages were: selective debridement, bactericidal or bacteriostatic action, and promotion of granulation tissue and healing factors. The main disadvantages were: pain, discomfort, prejudice, and weaknesses with the larval production market. Conclusion: The advantages found outweigh the disadvantages evidenced. Therefore, larvotherapy is favorable to treat wounds that are difficult to heal.

Fournier's Gangrene Diagnosis and Treatment: A Systematic Review

Fournier's gangrene (FG) is a perineal and abdominal necrotizing infection. It is most commonly found in middle-aged men with comorbidities such as diabetes mellitus. Initial symptoms are often indistinct and can rapidly progress to overwhelming infections with a relatively high mortality rate. It is crucial to make a prompt diagnosis so that the patient receives appropriate treatment. Given the importance of the identification of FG, we explored what were the most common signs and symptoms associated with FG, as well as distinguished the gold standard treatment. This systematic review utilized articles identified exclusively through PubMed using key terms such as Fournier's gangrene, signs, symptoms, and treatment. A total of 37 studies, including a total of 3,224 patients (3,093 males and 131 females), fit our inclusion parameters for relevance that included either the most identifiable presentation of FG or the most effective treatment. From our search, the most common clinical presentation was scrotal and labial pain, fever, abscesses, crepitus, erythema, and cellulitis. Diagnosis is made from clinical findings in conjunction with imaging. The gold standard for treatment was found to be a combination of surgical debridement, broad-spectrum antibiotics, and the administration of intravenous fluids. Further, patient survival was found to be directly related to the time from diagnosis to treatment when they underwent surgical debridement. The importance of early identification for improved outcomes or survival highlights the need for further studies or measures to enhance the identification of the signs and symptoms of FG.

[New aspects in Fournier's gangrene - a rapid review]

Fournier's gangrene (FG) is a sporadic, life-threatening, necrotising infection affecting the perineum, perineal region and genitals. Published literature provides hints that the outcome of this disease has failed to improve in recent years. We have therefore performed a rapid evidence synthesis by searching the database MEDLINE. The literature from 2020 was studied to identify new aspects to improve the care of FG patients and plan further therapeutic research. 18 publications were chosen for this review, 15 of these were original research and three systematic reviews. 12 were retrospective case series, 2 epidemiological studies, with one prospective clinical study, one systematic review and 2 systematic reviews, together with a meta-analysis. Most of the authors of the studies concluded that FG is still a severe disease with unacceptable mortality rates, so that there is urgent need for therapy improvement. New risk factors for higher mortality in FG have been identified in these studies, namely dyslipoproteinemia, diabetes mellitus, heart disease, as well as both acute and chronic kidney failure. Furthermore, 4 of the included studies investigated the association of SGLT2- and DDP4-inhibitors, which are drugs used in diabetes mellitus, and the incidence of FG. No studies reported a significant association between these drugs and FG, especially not a meta-analysis with 84 included studies. New promising concepts for wound conditioning are hyperbaric oxygenation (HBO), vacuum-assisted wound closure (VAC) and Maggot therapy (blowfly larvae). In summary, FG is still a severe disease, the prognosis has not improved in recent years and so there is an urgent need for improved therapy. This could only be achieved with further research in FG. In our opinion and due to the rarity of FG, this would be possible with a national registry study. For example, it might be possible to calculate risk stratification from this registry to identify patients who would benefit from treatment in a centre or with special wound conditioning.

Larval therapy from the patient’s perspective

Objective: to describe the perception of the patient undergoing larval therapy. Method: qualitative, exploratory-descriptive study, using oral history as a data collection technique and methodological framework, in the form of oral life history. Six patients with difficult-to-heal wounds participated in the study, followed by the dressing committee of a teaching hospital in Natal, Rio Grande do Norte, undergoing larval therapy. Results: the testimonies of the patients/collaborators point to various values, such as belief, fear, acceptance, improvement of the wound and pain. They revealed that there is no major objection and that clarification regarding the treatment instituted proved to be important in the acceptance decision. Conclusion: the feelings expressed by the patients, such as improvement of the wound, reduction of pain and odor, optimization of the healing process, emergence of sparks of hope regarding the return to their life, among others, translate the benefits of Larval Therapy (LT). Despite the seizure caused by the animal’s movement over the affected area and the disgust it causes to some professionals and people, LT was considered wonderful, especially for its effectiveness in cleaning the wound without the need for new invasive procedures such as cutting and surgical debridement.

Terapia larval sob a ótica do paciente

Objetivo: descrever a percepção do paciente submetido à terapia larval. Método: estudo qualitativo, exploratório-descritivo, tendo como técnica de coleta de dados e referencial metodológico a historia oral, na modalidade da história oral de vida. Participaram do estudo seis pacientes com feridas de difícil cicatrização, acompanhados pela comissão de curativos de um hospital escola em Natal, Rio Grande do Norte, submetidos à terapia larval. Resultados: os depoimentos dos pacientes/colaboradores apontam diversos valores, como crença, medo, aceitação, melhora da ferida e da dor. Revelaram que não há grande objeção e que o esclarecimento em relação ao tratamento instituído mostrou-se importante na decisão de aceitação. Conclusão: os sentimentos expressos pelos pacientes, como melhora da ferida, diminuição da dor e odor, otimização do processo de cicatrização, surgimento de centelhas de esperança quanto ao retorno à sua vida, dentre outros traduzem os benefícios da Terapia Larval (TL). Apesar do fervilhamento provocado pelo movimento do animal sobre a área acometida e da repulsa que causa a alguns profissionais e pessoas, a TL foi considerada maravilhosa, especialmente por sua eficácia na limpeza da ferida sem a necessidade de novos procedimentos invasivos como desbridamento cortante e cirúrgico.

Clinical study of Maggot therapy for Fournier's gangrene

Fournier's Gangrene is a fulminating necrotizing fasciitis of the perineum and genitalia. Standard treatment involves immediate excision of all necrotic tissue, aggressive antibiotic coverage, and supportive medical care. Still, the infection is commonly fatal or disfiguring. Wound treatment with disinfected blowfly larvae (maggot debridement therapy or MDT) has been shown to be highly effective, with multiple studies demonstrating effective debridement, disinfection, and promotion of granulation tissue. MDT also has been associated with preservation of viable tissue and minimised blood loss. This report describes a prospective clinical study of MDT for Fournier's gangrene aimed to test the hypothesis that early use of maggots could decrease the number of surgical treatments required to treat Fournier's gangrene. Subjects were provided with one initial surgical excision, followed by debridement using only medical grade Lucilia sericata larvae. Only two subjects were enrolled, both diabetic men. Intensive care and culture-directed antimicrobial coverage were administered as usual. Maggot debridement was associated with the disappearance of necrotic tissue, control of infection and granulation tissue growth. In both subjects, wounds healed without requiring further surgical resection or anatomical reconstruction. Maggot therapy decreased the number of surgical procedures that otherwise would have been necessary, and led to favourable outcomes.