Maggots to the Rescue - by Jaq Reed
13 December 2019
Maggots to the Rescue
Until the invention and mass production of penicillin in the 1940s, the prevailing method for treating infectious and chronic wounds was not by using antibiotics but through Maggot Debridement Therapy (MDT) (Hasler 757-752). Maggots were a main means of healing these sorts of wounds since ancient civilizations (Shi and Shofler s6) up until being widely replaced by antibiotic drugs in the past century. Now, there is increasing concern in the medical field surrounding the development of diseases immune to the antibiotics used to treat them (Centers for Disease Control). In spite of this recent dismissal of MDT, the practice may find another role in medicine as a treatment for wounds infected by these antibiotic-resistant bacteria. In “An Ancient Remedy Reexamined,” Jason Hasler discusses the benefits and drawbacks of MDT with a focus on the comparison of conventional treatments to larval therapy. Hasler concludes that although MDT has value as a treatment option, better education and training will be needed to fully implement it in medical facilities. Similarly, Shi and Shofler’s “Maggot Debridement Therapy: A Systematic Review” covers much of the research conducted on MDT and how it holds up against other more commonly used means of debridement. Though, Shi and Shofler write in much more detail and length about the specific processes of MDT which make it effective. Despite negative perceptions surrounding maggots in medicine, the evidence used in these works suggests MDT is effective in wound care and surpasses other more conventional treatments through its various processes; MDT also holds promise as an alternative to antibiotics in combatting antibiotic-resistant bacteria.
Although numerous studies indicate the benefits of Maggot Debridement Therapy, there remains potential objections from the medical community; a general sense of apprehension surrounds the treatment and has prevented MDT from full implementation.
As with any medicine or treatment entering mainstream usage in medical facilities, patients and hospitals have concern about MDT’s affordability (Hasler 761). Although there exists conflicting data on the annual cost of MDT, one recent meta-analysis concluded that when treating diabetic patients, the cost of treatment averaged around forty percent lower when using MDT versus conventional treatment (Shi and Shofler s10). Due to other existing figures which contradict this data, researchers struggle to definitively state whether MDT or conventional treatment is more expensive per year. However, taking into consideration the effectiveness of MDT as a treatment, over time larval therapy would likely end up costing less because it “prevent[s] hospital admission for surgical debridement” (Shi and Shofler s10). Another point of question is the level of pain patients using Maggot Debridement Therapy endure. Surveys indicate that “patients treated with larvae experience twice as much pain as patients treated with hydrogel” (Hasler 760) which raises concern about the comfort of those being treated with MDT. Even though there is an increased level of pain associated with MDT, medical staff can take steps to reduce this agitation. For example, in application by tea bag maggots do not roam freely in the wound, thereby causing less irritation (Hasler 760). Medical staff may also use medication to combat patient pain (Shi and Shofler s11). The larvae used in MDT are living creatures which require certain conditions to stay healthy and useful for therapy (Hasler 760; Shi and Shofler s10, s11). Limitations pertaining to the livelihood of medicinal maggots are inherent to MDT; the two biggest concerns are the transportation of maggots to medical facilities and the short amount of time available for treatment after they arrive. Fortunately, a study conducted on the survivability of maggots during delivery to hospitals found that “only 1% of maggots arrived late or dead” (Shi and Shofler s11). Since transportation is not a significant concern, the fact that maggots require application to a wound within twenty-four hours of their arrival in order to be useful for debridement (Shi and Shofler s11) remains the primary issue. With accurate planning and time management on the part of the medical staff, this time limitation is manageable, and MDT will prove an effective treatment despite the hassle of dealing with living organisms. Although these technical objections exist, perhaps more than anything what holds MDT back from its full potential as a treatment is, understandably, stigma surrounding the concept of using live larva in wound care (Hasler 761-762; Shi and Shofler s11). The perceived distasteful nature of the treatment presents the biggest hurdle facing MDT’s success as a practice. As stated by Turkman et al., these misconceptions “engenders a continued reluctance to adopt [MDT] as a mainstream treatment in appropriate wounds” (qtd. in Hasler 761). Better public education and training for medical professionals will help remedy this societal view.
Despite the medical community often considering MDT a last resort option, data gathered on the healing properties of larval therapy proves that not only is it a viable treatment for a variety of wounds, but it has even greater success than many conventional practices.
Studies show MDT’s superiority over other treatments in terms of removal of necrotic tissue and overall healing time. Traditional debridement techniques including various wound dressings and surgical debridement are often cumbersome, inaccurate, and can even “cause excessive trauma to the wound bed” (Shi and Shofler s8). MDT, however, proves a quicker and more thorough means of dead tissue removal than many of the techniques currently implemented. This effectiveness is exemplified by a study comparing MDT to conventional debridement conducted by Klaus and Stienwedel who state, “…‘80% of MDT wounds were debrided completely while only 48% of conventionally treated wounds were debrided completely’… [and] that in a 3-week time period, wounds treated with maggot therapy had twice the granulation tissue and one-third the necrotic tissue of wounds treated with conventional methods” (qtd. in Hasler 759-760). Zarchi and Jemec confirm these findings in a meta-analysis which concludes that “MDT was found to be significantly more effective as a debriding agent than hydrogel or a mixture of conventional therapy modalities (including hydrocolloid, hydrogel and saline moistened gauze)” (qtd. in Shi and Shofler s8). Maggot Debridement Therapy not only debrides wounds faster than other treatments but also clears them from bacteria and stimulates replacement of dead tissue with live and healthy tissues more quickly. Wound treatment using MDT results in a shorter amount of time that patients need to be in the care of a medical facility (Shi and Shofler s12). The mechanisms that take place during MDT’s process facilitate its superior efficacy over conventional methods.
MDT is a useful means of healing wounds through its effective processes including physical debridement, the anti-microbial and anti-inflammatory properties of the maggots’ secretions, and the activation of new healthy tissue growth. The primary way in which MDT treats wounds is the removal of necrotic tissue through the natural activity of maggot consumption, movement, and the digestive enzymes secreted during MDT which serve to break down this dead tissue (Shi and Shofler s8). The effectiveness of MDT is shown in a study conducted “using larval therapy and traditional dressing” by Turkman et al. which concluded that “…of the 34 patients, 29 (85%) found that all necrotic tissue was satisfactorily removed” (qtd. in Hasler 759). The secretions/excretions produced during MDT also have value outside of the debridement process as they contain agents which both inhibit bacterial growth and subdue excess inflammation caused by the human complement system (Shi and Shofler s8-s10). In fact, the anti-bacterial and anti-inflammatory properties of these enzymes have such effective outcomes that one study by Sherman and Shimoda found that “wounds treated with MDT 1–17 days prior to surgical closure had zero postoperative wound infections. However, …32% of the wounds that were not treated with MDT developed postoperative infections” (qtd. in Shi and Shofler s10). Additional research has indicated “that maggot excretions and secretions reduce complement up to 99.9%” (Shi and Shofler s10). The final way in which MDT encourages healing is through the promotion of new healthy tissue growth (Hasler 758). MDT has been shown to encourage the replacement of necrotic tissue with granulation tissue through cell migration and blood vessel growth in clinical studies by stimulating the wound via movement and enzyme secretion (Shi and Shofler s10). The processes of MDT combine to create an excellent treatment option that both cleans and contributes to faster healing; this has positive implications for the treatment of all types of wounds including those infected with antibiotic-resistant bacteria.
The increasing concern surrounding the rise of antibiotic-resistant bacteria creates a need to explore treatments alternative to antibiotics; Maggot Debridement Therapy poses a potential substitute for conventional methods when tending to surface wounds infected by superbugs. The CDC defines antibiotic-resistance as: “when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them;” it is currently one of the most serious threats facing public health, killing “at least 23,000 people” per year in the United States (CDC). The enzymes secreted by maggots during MDT show to have anti-bacterial properties which has led medical professionals to question its effectiveness against strains of bacteria commonly resistant to antibiotics. Research conducted testing MDT against these colonies found that it successfully combats “Gram-positive and Gram-negative bacterial strains, including Staphylococcus aureus, Pseudomonas aeruginosa, Methicillin-resistant Staphylococcus aureus (MRSA) and other drug-resistant pathogens” (Shi and Shofler s8-s10). The discovery of MDT’s success against strains of antibiotic-resistant bacteria commonly found in infectious wounds suggests that larval therapy has the potential to become a valuable method of treating infections without the use of antibiotics.
Even though a stigma surrounds MDT, the superior effectiveness of its processes against other types of practices outweighs any negatives and proves that Maggot Debridement therapy has value as a treatment in the fight against antibiotic-resistance. With better training for medical professionals and education for the public, the views surrounding MDT may be shifted so it can be considered a serious life-saving option for wound care. To confirm the possible role of MDT against superbugs in clinical settings, researchers need to conduct trials on the success rate of larval therapy in actual wounds infected with antibiotic-resistant bacteria rather than in the controlled environment of a sample colony. With time and awareness, the ancient practice of Maggot Debridement Therapy will surely find its place in modern medicine as the useful treatment that it is.
Centers for Disease Control and Prevention (CDC). “Antibiotic / Antimicrobial Resistance (AR / AMR).” Centers for Disease Control and Prevention, CDC, 4 Nov. 2019, www.cdc.gov/drugresistance/about.html. Accessed 13 Nov. 2019.
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Shi, Eric, and David Shofler. “Maggot Debridement Therapy: A Systematic Review.” British
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