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.
1. Wong CH, Wang YS. The diagnosis of necrotizing fasciitis. Curr Opin Infect Dis. 2005;18(2):101–106.
2. Ledingham IM, Tehrani MA. Diagnosis, clinical course and treatment of acute dermal gangrene. Br J Surg. 1975;62(5):364–372.
3. Cunningham JD, Silver L, Rudikoff D. Necrotizing fasciitis: a plea for early diagnosis and treatment. Mt Sinai J Med. 2001;68(4-5):253–261.
4. Childers BJ, Potyondy LD, Nachreiner R, et al. Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002;68(2):109–116.
5. Beck W, Weckbach A. Necrotizing fasciitis after closed pelvic ring fracture. Case report and review of the literature. Unfallchirurgie. 1993;19(4):234–239.
6. Robinson W, Norwood VH. The role of surgical maggots in the disinfection of osteomyelitis and other infected wounds. J Bone Joint Surg. 1933;15:409–412.
7. Simmons SW. The bactericidal properties of excretions of the maggot of Lucilia sericata. Bull Entomol Res. 1935;26:559–563.
8. Thomas S, Andrews AM, Hay NP, Bourgoise S. The antimicrobial activity of maggot secretions: results of a preliminary study. J Tissue Viability. 1999;9(4):127–132.
9. Steenvoorde P, Jukema GN. The anti-microbial activity of maggots: in-vivo results. J Tissue Viability. 2004;14(3):97–101.
10. Grassberger M, Fleischmann W. The biobag—a new device for the application of medicinal maggots. Dermatology. 2002;204(4):306.
11. Hasham S, Matteucci P, Stanly PR, Hart NB. Necrotising fasciitis. BMJ. 2005;330(7495):830-833.
12. Schnall SB. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am. 2004;86-A(4):869–870.
13. Baer WS. The treatment of chronic osteomyelitis with the maggot (larva of the blow fly). J Bone Joint Surg. 1931;13:438–475.
14. Wollina U, Karte K, Herold C, Looks A. Biosurgery in wound healing—the renaissance of maggot therapy. J Eur Acad Dermatol Venereol. 2000;14(4):285–289.
15. Sherman RA, Wyle F, Vulpe M. Maggot therapy for treating pressure ulcers in spinal cord injury patients. J Spinal Cord Med. 1995;18(2):71–74.
16. Courtenay M. The use of larval therapy in wound management in the UK. J Wound Care. 1999;8(4):177–179.
17. Robinson W. Ammonium bicarbonate secreted by surgical maggots stimulates healing in purulent wounds. Am J Surg. 1940;47:111–115.
18. Mumcuoglu KY, Ingber A, Gilead L, et al. Maggot therapy for the treatment of diabetic foot ulcers. Diabetes Care. 1998;21(11):2030–2031.
19. Simmons SW. A bactericidal principle in excretions of surgical maggots which destroys important etiological agents of pyogenic infections. J Bacteriol. 1935;30(3):253–267.
20. Mumcuoglu KY. Clinical applications for maggots in wound care. Am J Clin Dermatol. 2001;2(4):219–227.
21. Nigam Y, Bexfield A, Thomas S, Ratcliffe NA. Maggot therapy: the science and implication for CAM part II—maggots combat infection. Evid Based Complement Alternat Med. 2006;3(3):303–308.
22. Wolff H, Hansson C. Larval therapy—an effective method for ulcer debridement. Clin Exp Dermatol. 2003;28(2):134–137.
23. Jukema GN, Menon AG, Bernards AT, Steenvoorde P, Taheri Rastegar A,van Dissel JT. Amputation-sparing surgery by nature: “surgical” maggots revisited. Clin Infect Dis. 2002;35(12):1566–1571.
24. Rozeboom A, Steenvoorde P, Hartgrink HH, Jukema GN. Necrotizing fasciitis of the leg following a simple pelvic fracture: case report and literature review. J Wound Care. 2006;15(3):117–120.
25. Dunn C, Raghavan U, Pfleiderer AG. The use of maggots in head and neck necrotizing fasciitis. J Laryngol Otol. 2002;116(1):70–72.
26. Teich S, Myers RA. Maggot therapy for severe skin infections. South Med J. 1986;79(9):1153–1155.
27. Contreras RJ. Contraindications to Maggot Debridement Therapy. CAWC. Available at: http://www.cawc.net/open/wcc/3-1/contreras.html. Accessed February 2, 2007.
28. Sherman RA. Maggot therapy for foot and leg wounds. Int J Low Extrem Wounds. 2002;1(2):135–142.
29. Steenvoorde P, van Doorn L, Brehm V, Verdegaal S. The use of cadaveric donor fascia lata in open knee-joint due to necrotizing fasciitis. Presented at the European Tissue Repair Society, September 13–16, 2006, Pisa, Italy.
30. de Geus HR, van der Klooster JM. Vacuum-assisted closure in the treatment of large skin defects due to necrotizing fasciitis. Intensive Care Med. 2005;31(4):601.