Maggot Debridement Therapy in Necrotizing Fasciitis Reduces the Number of Surgical Debridements
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A 46-year-old man with no relevant medical history besides an appendectomy and a perianal fistula more than 20 years before current presentation was referred to the authors’ hospital with a Fournier's gangrene after he was first examined in the emergency department of the referring hospital. The patient had a history of smoking and consumed about 36–56 g of alcohol daily (3–4 units). The patient presented with a red and tender right scrotum, which in retrospect, had been present for 7 days. His general practitioner had treated him with oral Ciprofloxacin® over the preceding 4 days for a presumed infected sebaceous gland in the right groin. The patient was taken to the operating room after administration of broad-spectrum antibiotic therapy with netilmycin amoxicillin, and metronidazole. An extensive area of fasciitis was found predominantly on the right side of the abdomen, scrotum, and perineum. A large part of the abdominal skin (including abdominal fascia) and scrotum were excised (Figure 1). Initial gram-staining showed a mixed culture. Definitive cultures showed bacteroides, diphtheroids, and Enterococcus faecalis. Six surgical debridements were performed over the following 10 days.
It was decided to perform MDT because sepsis persisted and the wound did not show any signs of healing. An average of 20–30 sterile Lucilia sericata maggots were placed in each biobag (Vitapad®, Polymedics Bioproducts, B.V.B.A. Peer, Belgium) on the wound (Figure 2). The patient was treated with the maggots for 19 days. A total of 1,200 maggots were applied. The wound was well granulated after the maggot treatment (32 days after initial presentation to the authors’ hospital). The wound was partially closed secondarily and a mesh graft was used to close the rest of the wound. Postoperative course was uncomplicated following this last operation. The patient was discharged from the hospital, returned to work, and has remained in good condition for more than 3 years after the last operation (Figure 3).
Patients who presented to the authors’ hospital with necrotizing fasciitis were treated with a combination of surgical debridement, antibiotic therapy, and MDT. Patient and treatment characteristics were recorded from the patients’ charts. All MDT applications where discontinued when the wounds were 100% red and fully granulated. Discontinuation of the therapy was a clinical decision. Throughout this study, all maggot applications where performed using the contained technique (biobags). In the biobag technique, larvae are enclosed between 2 layers of 0.5-mm polyvinyl alcohol hydrosponge, which are heat-sealed, and then a small cube of spacer material is inserted to prevent bag collapse.10 The bag containing the maggots is placed inside the wound. A net is placed over the bag and taped to an adhesive on the wound edges. Wet gauze and a light bandage are wrapped over the net. Catheters are placed inside the bandages in order to wet the gauze 3 times daily with normal saline solution (0.9%)—this prevents maggot death from dehydration. Every 3 to 4 days new contained maggots were placed on the wound until thorough debridement was reached. The gauze was changed daily. Maggots derive nutrients through a process known as “extracorporeal digestion.” They secrete proteolytic enzymes that liquefy necrotic tissue. The enzymes move freely through the biobag.
Possible differences in patient and treatment characteristics and outcomes were statistically tested using SPSS™ version 12.0.1 for Windows® and then evaluated. For analysis, the patients were split into 2 groups according to the median number of days of starting MDT after diagnosis of the necrotizing fasciitis.
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