MAGGOT THERAPY - ONE OF THE EMERGING THERAPY IN WOUND HEALING

While technological advances have led to significant enhancements in medical care, as well as wound care, non healing wounds still stay a big problem. 

where Globally, it's calculable that 1–2% of the population in developing countries expertise a chronic wound throughout their lifetime, creating it a silent epidemic. 

As chronic wounds need long-run care, the utilization of this medical aid has the potential to possess a significant impact on care systems. 

In diabetic foot ulcers with the matter of microorganism resistance, maggot therapy has been used as an alternate treatment of those ulcers. 

The initial controlled clinical trials weren't begun till 1990, and it absolutely was not until simply ten years past that the U.S Food and Drug Administration (FDA) initially granted selling clearance to healthful maggots as a medical device. The indications for that product were restricted to debridement. 

Clinical proof of maggot-induced medical care and growth stimulation wasn't sturdy enough to win over regulators at that time. 

Clinicians ought to necessary to in decisive at that stage of wound healing should the treatment be administered, for what purpose, and once to prevent the treatment. 

Different issues embrace the shape of treatment to be provided (whether loose or bagged), however the treatment outcomes ought to be measured and quantified, in addition as any potential aspect effects.

Maggot debridement therapy will be used for acute and chronic wounds requiring debridement. 

In literature, the rumored success rate varies from 80% to 90%.

MAGGOTS CONTAINS

INDICATION AND CONTRAINDICATION OF MAGGOT THERAPY

Clinical Indications are 

• Diabetic foot ulcer
• Ischemic leg ulcers
• Osteomyelitis
• Burn wounds as operative treatment for a necrotizing fasciitis or for the interference of (further) amputations. 
• Wounds like pressure ulcers
• Venous leg ulcers
• Peripheral blood vessel diseases 
• Acute surgical wounds as treatment and as preparation for surgical wound closure.

Clinical Contraindication are

• Open wounds into the abdominal cavity, due to the chance of organ lesions. 
• Pyoderma gangrenosum in patients with immunological disorder therapy 
• Septic arthritis. Caution is suggested in treating wounds close to giant arterial blood vessels and veins. 
• Wounds heavily contaminated with genus Pseudomonas aeruginosa could have restricted the impact of maggot debridement. 
• Very dry wounds could also be a relative contraindication as a result of maggots needing a moist environment.

Maggot therapy is used in diabetic foot

Photo credit: Alexsey Nosenko (Wikipedia commons) 

WOUND DEBRIDEMENT

Wound debridement is outlined because the removal of foreign material and dead contaminated tissue from (or adjacent to) a traumatic or infected lesion to reveal healthy tissue,it's going to also embrace removal of foreign material that has become embedded within the wound. 

The main reason for debriding a wound is to avoid substratum for microorganism growth, ongoing inflammation, and leukocyte infiltration with delayed progression to the proliferative and remodeling phases of wound healing, compromised restoration of the structure and performance of the skin,odor management issues, and different negative effects.

Maggot debridement therapy is the intentional application of live, “medical-grade” fly larvae to wounds so as to result in operation, disinfection, and ultimately wound healing.

Several kinds of debridement are available.

The most usually best-known is 

• surgical or sharp debridement
• nonsurgical ways have more and more achieved attention 
• enzymatic agents
• chemical agents
• autolytic debridement
• biosurgical debridement
• wet-to-dry dressings
• Hydrotherapy
• aggressive irrigations and a few different types of debridement. 

Operation has been divided into 

• selective 
• nonselective methods looking on whether or not solely dead tissue is removed.

Selective debridement methods can, be mentioned as partial surgery, use of enzymes, diffusion agents, autolysis, and maggot therapy.

Each maggot is capable of removing 25 mg of necrotic material from the wound within 24 hrs.

WOUND HEALING

Wound healing is classically delineate as four distinct however overlapping physiological phases of repair and rebuilding: 

• Homeostasis
• Inflammation
• proliferation and 
• remodeling and maturing  

With every phase, new cells are recruited into the realm to perform the work, or cells already present alter their activity to secrete new cytokines or perform new duties, in response to dynamic conditions within the wound (bleeding, hypoxia, alterations in cytokine concentrations, etc.). 

Once not needed, the cells bear programmed cell death and are removed or engulfed by other cells (i.e., macrophages). 

Normally, these four waves within the healing method progress quickly and smoothly, one into the next. 

However often healing could stagnate, and also the wound is claimed to be chronic. 

Wound healing is also at bay at any part (or even whereas undergoing a mixture of phases), but generally it's inside the inflammatory phase: dead, infected detritus might not be adequately off from the wound bed, and/or it'd not be potential for the body to eradicate the native infection, and/or the proteases and different damaging product of inflammation by clearing the recently formed cellular and extracellular matrix as quick because it is being arranged down. 

It's during this context that debridement, disinfection, or cellular proliferation and migration 

are thus important, for they will push the stagnant wound into succeeding part of healing. 

Person having wound in the leg 

WOUND DISINFECTION

The natural environment of L. sericata larvae is putrefaction organic matter reminiscent of a dead body or excrement. 

Therefore, maggot would be well-protected from infection.

Maggot therapy is one in all the few extremely effective strategies of disinfection which might safely and inexpensively be continuing throughout the healing process, which may make a case for why it remains one of the methods of maintenance debridement best related to quicker wound healing.

Maggots conjointly fight microorganism in their a lot of resistant form: biofilm. In distinction to life style (“planktonic”) individual bacteria, biofilm may be a structured community of 1 or more species of microorganism cells, living closely in an enclosed, protective, self-produced compound matrix, associate degreed adherent to an inert or living surface. 

Antibiofilm activity is efficacious as a result of biofilm is very proof against the penetration and booming activity of the human system and antibiotics. 

Biofilm may be a significantly tough downside in chronic wounds. one in all the foremost powerful tools we've against biofilm is physically wearing it away (i.e., brushing our teeth to free ourselves of dental biofilm). 

Several therapists impose brushing to rid a wound of biofilm. 

It's affordable to assume that the maggots are serving to rid a wound of biofilm just by crawling over it with their rough bodies. 

What was significantly surprising, though, was the invention that maggot enzymes are capable of dissolving biofilm and inhibiting the expansion of recent biofilm. 

This has been shown a minimum for Staphylococcus aureus and Pseudomonas aeruginosa biofilm. 

Numerous case reports have reputed wound medical care following maggot medical care, however controlled clinical proof of maggot-induced antimicrobial activity has been sparse, till recently. 

Clinical connectedness of maggot-induced disinfection by planning a case-control study of maggot therapy for lower extremity wounds in hospice patients and recording the antibiotics prescribed by the patients’ primary clinicians, as a live of clinically vital infection.

MECHANISM OF MAGGOT HELPS IN WOUND DEBRIDEMENT

Larvae are coated by minute spines that contend the wound base because the maggots crawl about, loosening detritus as will a surgeon’s rasper or file. 

The mandibles, within the style of “mouth hooks,” are wont to facilitate pull the maggot’s body forward as it crawls and to probe each nook and cranny for food or shelter. 

The maggot doesn't “bite off” pieces of tissue, however it rather secretes and excretes its biological process enzymes (alimentary secretions and excretions or enzymes), the consequence of that is that digestion begins within the wound bed, outside of the grub’s own body. 

The death tissue liquefies, and also the maggots will then simply imbibe it. 

The physical movement of the maggot over the wound, plowing the tissue and spreading its enzymes because it goes, contributes considerably to the operation effort.

OTHER MODE OF ACTION OF MAGGOT THERAPY

Kill Bacteria Ingested microorganisms are killed within the gut of the maggots

Environmental Production of ammonia will increase pH scale and inhibit growths of bacteria Stimulate wound healing combined impact of mentioned earlier effects. 

Direct stimulatory mechanical effect Inhibit Biofilm Inhibit and break down biofilms of varied bacteria

EFFICACY OF MAGGOT THERAPY(MT)

A standardized clinical apply guideline for the appliance of MT in terms of the amount of larvae, duration, and frequency of dressing is indicated. 

Maggot therapy has long been recognized as a secure and effective treatment for wounds. It is related to 3 broad actions: 

• surgical procedure

• disinfection and 

• hastened tissue growth.

It ought to be thought-about an inexpensive variety in patients with chronic wounds and a primary choice for those that aren't suitable surgical procedure or are in low resource settings. 

Once maggot therapy has been used for debridement alone, some studies have shown quicker overall healing, others have not. 

There have been no serious adverse effects from the MT, indicating it's a secure intervention for wound healing, so assuaging issues for the security of patients.

Improved analysis methodologies with larger sample sizes and longer follow-up periods for study participants should be obligatory in experimental styles to determine the typical period for complete healing, that can be of nice advantage for future research.

Evidence of maggots' debridement efficaciousness is irrefutable. 

Clarity continues to be required relating to maggot therapy’s role in promoting wound closure. 

Those studies that have advised or incontestable considerably faster wound closure have checked out short-term findings: healing that happens throughout or shortly once maggot therapy is administered. 

Measurements of cost-efficacy, antimicrobial activity, and relative safety ought to even be incorporated into such a study, so as to capture the maximum amount knowledge and address as several views as potential regarding the clinical utility of maggot therapy for non healing wounds

The physical effects of maggots on the wound and therefore the bioactive molecules that they secrete don't last long after therapy, therefore wounds that do not heal directly after grub debridement are at risk for 

• Recolonization
• Infection
• stagnation and 
• necrosis.

The maggots in Biobags required twenty eight days to debride and unconfined maggots needed solely fourteen days, each therapies were terribly effective in surgery compared to hydrogel, that cleansed the injuries in seventy two days.

The origin of reported pain throughout maggot application isn't known, as a result of the wound-healing effect of maggots isn't concerning their direct creep action within the wound surface. No allergies were ever noted.

Surgical debridement of wound by using surgical instrument

FUTURE TECHNOLOGY

Technological advances in material style have allowed makers to form single-piece, hinged, cage-like dressings that confine the maggots to the wound called “maggot confinement dressings” ; these merchandise give the maggots with free and complete access to the wound whereas preventing them from escaping. 

These dressings are abundant, easier and fewer long to use than this method. Many researchers have tried to isolate the wound-healing molecules that underlie the proteolytic, antimicrobial, and growth-promoting activity of maggot therapy. 

Some propose that such compounds might sometimes replace the maggot itself. modern dressing materials have simplified the maggot therapy procedure and decreased the chance of escape. 

The establishment of laboratories throughout the world, in conjunction with access to long traveller service in many regions, has created medicinal maggots without delay offered to scores of people.

Maggots are in medical packaging 

Photo credit: Enter (Wikipedia commons) 

CONCLUSION

Researchers still extend our understanding concerning wound healing as they explore the mechanisms by which maggots facilitate wound healing. 

It's unsure whether or not maggot-derived merchandise could sometimes replace live larvae for wound care.

Future studies ought to conjointly target treating peripheral blood vessel disease in patients with ankle-brachial pressure index, which is most frequently related to pain, poor vascularization, and concurrent infection.

REFERENCE