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Maggot therapy

Maggot therapy

Overview

Maggot therapy is a type of biotherapy
Biotherapy
Zootherapy is the use of living animals for medical treatment or as an adjunct to medical diagnosis.-Overview:Zootherapy is the use of living organisms to diagnose, treat or cure disease or disease symptoms...

 involving the intentional introduction of live, disinfected maggot
Maggot
In everyday speech the word maggot means the larva of a fly ; it is applied in particular to the larvae of Brachyceran flies, such as houseflies, cheese flies, and blowflies, rather than larvae of the Nematocera, such as mosquitoes and Crane flies...

s (fly larvae) into the non-healing skin and soft tissue wound(s)
Wound
A wound is a type of injury in which skin is torn, cut or punctured , or where blunt force trauma causes a contusion . In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.-Open:...

 of a human or animal for the purpose of cleaning out the necrotic
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...

 tissue within a wound (debridement
Debridement
Debridement is the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue...

) and disinfection. It was long believed that the debridement is selective on necrotic tissue but this has been questioned by recent literature.

Written records have documented that maggots have been used since antiquity
Ancient history
Ancient history is the study of the written past from the beginning of recorded human history to the Early Middle Ages. The span of recorded history is roughly 5,000 years, with Cuneiform script, the oldest discovered form of coherent writing, from the protoliterate period around the 30th century BC...

 as a wound treatment.
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Encyclopedia

Maggot therapy is a type of biotherapy
Biotherapy
Zootherapy is the use of living animals for medical treatment or as an adjunct to medical diagnosis.-Overview:Zootherapy is the use of living organisms to diagnose, treat or cure disease or disease symptoms...

 involving the intentional introduction of live, disinfected maggot
Maggot
In everyday speech the word maggot means the larva of a fly ; it is applied in particular to the larvae of Brachyceran flies, such as houseflies, cheese flies, and blowflies, rather than larvae of the Nematocera, such as mosquitoes and Crane flies...

s (fly larvae) into the non-healing skin and soft tissue wound(s)
Wound
A wound is a type of injury in which skin is torn, cut or punctured , or where blunt force trauma causes a contusion . In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.-Open:...

 of a human or animal for the purpose of cleaning out the necrotic
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...

 tissue within a wound (debridement
Debridement
Debridement is the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue...

) and disinfection. It was long believed that the debridement is selective on necrotic tissue but this has been questioned by recent literature.

Early history


Written records have documented that maggots have been used since antiquity
Ancient history
Ancient history is the study of the written past from the beginning of recorded human history to the Early Middle Ages. The span of recorded history is roughly 5,000 years, with Cuneiform script, the oldest discovered form of coherent writing, from the protoliterate period around the 30th century BC...

 as a wound treatment. There are reports of the successful use of maggots for wound
Wound
A wound is a type of injury in which skin is torn, cut or punctured , or where blunt force trauma causes a contusion . In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.-Open:...

 healing by Maya
Maya civilization
The Maya is a Mesoamerican civilization, noted for the only known fully developed written language of the pre-Columbian Americas, as well as for its art, architecture, and mathematical and astronomical systems. Initially established during the Pre-Classic period The Maya is a Mesoamerican...

 Indians and Aboriginal
Indigenous Australians
Indigenous Australians are the original inhabitants of the Australian continent and nearby islands. The Aboriginal Indigenous Australians migrated from the Indian continent around 75,000 to 100,000 years ago....

 tribes in Australia. There also have been reports of the use of maggot treatment in Renaissance
Renaissance
The Renaissance was a cultural movement that spanned roughly the 14th to the 17th century, beginning in Italy in the Late Middle Ages and later spreading to the rest of Europe. The term is also used more loosely to refer to the historical era, but since the changes of the Renaissance were not...

 times. During warfare, many military physicians observed that soldiers whose wounds had become colonized with maggots experienced significantly less morbidity and mortality than soldiers whose wounds had not become colonized. These physicians included Napoleon’s general surgeon, Baron Dominique Larrey, who reported during France's Egyptian campaign in Syria, 1798–1801, that certain species of fly destroyed only dead tissue and had a positive effect on wound healing.

Dr. Joseph Jones
Joseph Jones
Joseph Jones may refer to:* Joseph E. Jones, US state legislator from Wisconsin* Joseph Jones , U.S. statesman, Virginia delegate in Continental Congress* Joseph Jones , U.S...

, a ranking Confederate
Confederate States of America
The Confederate States of America was a government set up from 1861 to 1865 by 11 Southern slave states of the United States of America that had declared their secession from the U.S...

 medical officer during the American Civil War
American Civil War
The American Civil War was a civil war fought in the United States of America. In response to the election of Abraham Lincoln as President of the United States, 11 southern slave states declared their secession from the United States and formed the Confederate States of America ; the other 25...

, is quoted as follows, "I have frequently seen neglected wounds ... filled with maggots ... as far as my experience extends, these worms only destroy dead tissues, and do not injure specifically the well parts." The first therapeutic use of maggots is credited to a second Confederate medical officer Dr. J.F. Zacharias, who reported during the American Civil War that, "Maggots ... in a single day would clean a wound much better than any agents we had at our command ... I am sure I saved many lives by their use." He recorded a high survival rate in patients he treated with maggots.

During World War I
World War I
World War I , which was predominantly called the World War or the Great War from its occurrence until 1939, and the First World War or World War I thereafter, was a major war centred in Europe that began on 28 July 1914 and lasted until 11 November 1918...

, Dr. William S. Baer, an orthopedic surgeon, recognized on the battlefield the efficacy of maggot colonization for healing wounds. He observed one soldier left for several days on the battlefield who had sustained compound fractures of the femur
Femur
The femur , or thigh bone, is the most proximal bone of the leg in tetrapod vertebrates capable of walking or jumping, such as most land mammals, birds, many reptiles such as lizards, and amphibians such as frogs. In vertebrates with four legs such as dogs and horses, the femur is found only in...

 and large flesh wounds of the abdomen
Abdomen
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...

 and scrotum
Scrotum
In some male mammals the scrotum is a dual-chambered protuberance of skin and muscle containing the testicles and divided by a septum. It is an extension of the perineum, and is located between the penis and anus. In humans and some other mammals, the base of the scrotum becomes covered with curly...

. When the soldier arrived at the hospital, he had no signs of fever despite the serious nature of his injuries and his prolonged exposure to the elements without food or water. When his clothes were removed, it was seen that "thousands and thousands of maggots filled the entire wounded area." To Dr. Baer's surprise, when these maggots were removed "there was practically no bare bone to be seen and the internal structure of the wounded bone as well as the surrounding parts was entirely covered with most beautiful pink tissue that one could imagine." This case took place at a time when the death rate for compound fractures of the femur was about 75-80%.

Modern use


While at Johns Hopkins University
Johns Hopkins University
The Johns Hopkins University, commonly referred to as Johns Hopkins, JHU, or simply Hopkins, is a private research university based in Baltimore, Maryland, United States...

 in 1929, Dr. Baer introduced maggots into 21 patients with intractable chronic osteomyelitis
Osteomyelitis
Osteomyelitis simply means an infection of the bone or bone marrow...

. He observed rapid debridement, reductions in the number of pathogenic organisms, reduced odor levels, alkalinization of wound beds, and ideal rates of healing. All 21 patients' open lesions were completely healed and they were released from the hospital after two months of maggot therapy.

After the publication of Dr. Baer's results in 1931, maggot therapy for wound care became very common, particularly in the United States. The Lederle pharmaceutical company commercially produced "Surgical Maggots", larvae of the green bottle fly
Green bottle fly
The common green bottle fly is a common blow-fly found in most areas of the world, and the most well-known of the numerous green bottle fly species. It is 10–14 mm long, slightly larger than a housefly, and has brilliant, metallic, blue-green or golden coloration with black markings. It has...

, which primarily feed on the necrotic tissue of the living host without attacking living tissue. Between 1930 and 1940, more than 100 medical papers were published on maggot therapy. Medical literature of this time contains many references to the successful use of maggots in chronic or infected wounds including osteomyelitis
Osteomyelitis
Osteomyelitis simply means an infection of the bone or bone marrow...

, abscesses, burns, sub-acute mastoiditis
Mastoiditis
Mastoiditis is an infection of mastoid process, the portion of the temporal bone of the skull that is behind the ear which contains open, air-containing spaces. It is usually caused by untreated acute otitis media and used to be a leading cause of child mortality. With the development of...

, and chronic empyema
Empyema
Pleural empyema is an accumulation of pus in the pleural cavity. Most pleural empyemas arise from an infection within the lung , often associated with parapneumonic effusions. There are three stages: exudative, fibrinopurulent and organizing. In the exudative stage, the pus accumulates...

.

More than 300 American hospitals employed maggot therapy during the 1940s. The extensive use of maggot therapy prior to World War II was curtailed when the discovery and growing use of penicillin
Penicillin
Penicillin is a group of antibiotics derived from Penicillium fungi. They include penicillin G, procaine penicillin, benzathine penicillin, and penicillin V....

 caused it to be deemed outdated. Due to the lack of conventional medicines, maggot therapy was used by Allied military medical staff in Japanese prisoner of war camps in the Far East throughout World War II.

Reintroduction



With the advent of antibiotic-resistant bacteria, Dr. Ronald Sherman, a physician previously at the University of California, Irvine
University of California, Irvine
The University of California, Irvine , founded in 1965, is one of the ten campuses of the University of California, located in Irvine, California, USA...

, sought to re-introduce maggot therapy into the armamentarium of modern medical care. In 1989, he set up fly breeding facilities at the Veterans Affairs
United States Department of Veterans Affairs
The United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense...

 Medical Center in Long Beach, California
Long Beach, California
Long Beach is a city situated in Los Angeles County in Southern California, on the Pacific coast of the United States. The city is the 36th-largest city in the nation and the seventh-largest in California. As of 2010, its population was 462,257...

, in order to use maggots for the treatment of wounds. That year, using a Paralyzed Veterans of America
Paralyzed Veterans of America
The Paralyzed Veterans of America is a veterans' service organization in the United States of America, founded in 1946. The organization holds 34 chapters and 61 National Service Offices in the United States...

 grant, he initiated a prospective controlled clinical trial of maggot therapy for spinal cord patients with pressure ulcers who had failed two or more courses of conventional wound care.

The therapeutic maggot used by Sherman is a strain of the green bottle fly (Phaenicia sericata) and marketed under the brand name Medical Maggots.

Over fifty scientific papers have been published that describe the medical use of maggots. Six thousand maggot therapy patients have been included in case histories or other studies. About 400 patients have been documented within clinical studies, most of them are included in a British study financed by NHS.

In the medical literature, limb salvage rates with maggot therapy are about 40% to 50%. Some report success rates of 70% to 80%, though definitions of "success" can vary.

In a 2007 preliminary trial, maggots were used successfully to treat patients whose wounds were infected with MRSA, a bacterium (Staphylococcus aureus) with resistance to most antibiotics, including methicillin
Methicillin
Meticillin or methicillin is a narrow-spectrum beta-lactam antibiotic of the penicillin class. It should not be confused with the antibiotic metacycline.-History:Methicillin was developed by Beecham in 1959...

. Some of these strains include flesh eating bacteria
Necrotizing fasciitis
Necrotizing fasciitis , commonly known as flesh-eating disease or Flesh-eating bacteria syndrome, is a rare infection of the deeper layers of skin and subcutaneous tissues, easily spreading across the fascial plane within the subcutaneous tissue.Necrotizing fasciitis is a quickly progressing and...

 causing frequent deaths upon infection of deep tissue. Maggots clean up the already dead tissue thus preventing further infection spread.

In 1995, a handful of doctors in 4 countries were using maggot therapy. Today, any physician in the U.S. can prescribe maggot therapy. There are over 800 health care centers in the United States that have utilized maggot therapy. Over 4,000 therapists are using maggot therapy in 20 countries. Approximately 50,000 treatments were applied to wounds in the year 2006.

Regulation


In January 2004, the U.S. Food and Drug Administration (FDA) granted permission to produce and market maggots for use in humans or animals as a prescription-only medical device for the following indications: "For debriding non-healing necrotic skin and soft tissue wounds, including pressure ulcers, venous stasis ulcers, neuropathic foot ulcers, and non-healing traumatic or post-surgical wounds." In February 2004, the British National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...

 (NHS) permitted its doctors to prescribe maggot therapy. In Europe, Canada and Japan maggots are classified as medicinal drugs, needing a full market licence. In US maggots for medicinal use are classified as a device.

Veterinary use


The use of maggots to clean dead tissue from animal wounds is part of folk medicine in many parts of the world. It is particularly helpful with chronic osteomyelitis
Osteomyelitis
Osteomyelitis simply means an infection of the bone or bone marrow...

, chronic ulcers, and other pus
Pus
Pus is a viscous exudate, typically whitish-yellow, yellow, or yellow-brown, formed at the site of inflammatory during infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection of pus within or beneath the epidermis is known as a pustule or...

-producing infections that are frequently caused by chafing due to work equipment. Maggot therapy for horses in the United States was re-introduced after a study published in 2003 by veterinarian Dr. Scott Morrison. This therapy is used in horses for conditions such as osteomyelitis secondary to laminitis, sub-solar abscesses leading to osteomyelitis, post-surgical treatment of street-nail procedure for puncture wounds infecting the navicular bursa, canker, non-healing ulcers on the frog, and post-surgical site cleaning for keratoma removal.

Application of maggot wound dressings


Maggots are contained in a cage-like dressing over the wound for two days. The maggots may be allowed to move freely within that cage, with the wound floor acting as the bottom of the cage; or the maggots may be contained within a sealed pouch, placed on top of the wound. The dressing must be kept air permeable because maggots require oxygen to live. When maggots are satiated, they become substantially larger and seek to leave the site of a wound. Multiple two-day courses of maggot therapy may be administered depending on the severity of the non-healing wound.

Maggots can never reproduce in the wound since they are still in the larval stage and too immature to do so. Reproduction can only occur when they become adult flies
Fließ
Fließ is a municipality in the Landeck district and is located5 km south of Landeck on the upper course of the Inn River. It has 9 hamlets and was already populated at the roman age; the village itself was founded around the 6th century. After a conflagration in 1933 Fließ was restored more...

 and mate.

Mechanisms of action


The maggots have one principal action reported in the medical literature:
  • debride
    Debridement
    Debridement is the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue...

     wounds by dissolving only necrotic, infected tissue.

Disinfection of the wound by killing bacteria and healing could not be proved by the largest clinical study available.

Maggot therapy has been shown to accelerate debridement of necrotic wounds and reduce the bacterial load of the wound, reduced wound odor, and lessening the pain in some cases. In about 1/3 of all patients pain is increased. The combination and interactions of these actions make maggots an extremely potent tool in wound debridement.

Maggot therapy is further compatible with other wound care therapies such as antibiotics, negative pressure wound therapy
Negative Pressure Wound Therapy
Negative-pressure wound therapy is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of first and second degree burns. The therapy involves the controlled application of sub-atmospheric pressure to the local wound environment, using a...

 (NPWT), skin grafting and hyperbaric oxygen therapy. While maggot therapy can not be used simultaneously with NPWT, it can be used prior to NPWT to debride a wound so that it can be later closed with NPWT. Similarly, while maggot therapy can not be used simultaneously with skin grafting, it can be used prior to skin grafting to debride a wound so that it can be later closed with skin grafting.

Debridement


The debridement
Debridement
Debridement is the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue...

 of necrotic tissue is a prerequisite for successful wound care. If debridement does not take place, wound repair is significantly impaired. Necrotic tissue in the wound is not only an obstacle for localized treatment, but becomes an ideal breeding ground for bacteria and may lead to gangrene
Gangrene
Gangrene is a serious and potentially life-threatening condition that arises when a considerable mass of body tissue dies . This may occur after an injury or infection, or in people suffering from any chronic health problem affecting blood circulation. The primary cause of gangrene is reduced blood...

, necessitating limb amputation
Amputation
Amputation is the removal of a body extremity by trauma, prolonged constriction, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for...

, and potentially fatal sepsis
Sepsis
Sepsis is a potentially deadly medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues...

.

Surgeons cannot be very precise in debriding dead tissue while leaving living tissue. The human eye is simply not very discriminating in identifying healthy tissue from necrotic tissue, and surgeons only have a very limited time to operate while their patient is under anesthesia. Consequently, surgeons use their scalpels to remove far more viable tissue than is needed, producing a wound larger than necessary that has more bleeding and a greater chance of becoming infected. Patients also experience more wound-associated pain after removal of healthy tissue. Wound care therapists can find themselves needing to debride a wound day after day, deeper and deeper; this is impractical as surgeons simply do not have the time to perform frequent surgical debridements. The requirement for frequent surgical debridement complicates and lengthens wound healing, lengthening hospital stays and increasing costs.

In maggot therapy, a large number of small maggots consume necrotic tissue far more precisely than is possible in a normal surgical operation, and can debride a wound in a day or two. While in the past it was believed that maggots do not damage healthy tissue, this is in doubt now. They derive nutrients through a process known as "extracorporeal digestion" by secreting a broad spectrum of proteolytic enzymes that liquefy
Liquification
In physics, to liquefy means to turn something into the liquid state.-In Geology:In geology, liquefaction refers to the process by which saturated, unconsolidated sediments are transformed into a substance that acts like a liquid.Earthquakes can cause soil liquefaction where loosely packed,...

 necrotic tissue, and absorb the semi-liquid result within a few days. In an optimum wound environment maggots molt twice, increasing in length from 1–2 mm to 8–10 mm, and in girth, within a period of 3–4 days by ingesting necrotic tissue, leaving a clean wound free of necrotic tissue when they are removed. When they stay longer or too many are used, healthy tissue is removed as well.

Disinfection


Any wound infection is always a serious medical complication. Infected living tissue cannot heal. If the wound is infected with an antibiotic-resistant bacterial strain, it becomes difficult or impossible to treat the underlying infection and for any healing to occur. Wound infection could further be limb- and life-threatening. When maggots successfully debride a necrotic wound, a source of wound infection is removed.

For wounds already infected, maggot therapy is effective even against some antibiotic-resistant bacteria. Maggot secretions were first experimentally shown in the 1930s to possess potent antimicrobial activity. As early as 1957, a specific antibiotic factor was found in maggot secretions and published in the journal Nature. Secretions believed to have broad-spectrum antimicrobial activity include allantoin
Allantoin
Allantoin is a chemical compound with formula C4H6N4O3. It is also called 5-ureidohydantoin or glyoxyldiureide. It is a diureide of glyoxylic acid....

, urea
Urea
Urea or carbamide is an organic compound with the chemical formula CO2. The molecule has two —NH2 groups joined by a carbonyl functional group....

, phenylacetic acid
Phenylacetic acid
Phenylacetic acid is an organic compound containing a phenyl functional group and a carboxylic acid functional group. It is a white solid with a disagreeable odor...

, phenylacetaldehyde
Phenylacetaldehyde
Phenylacetaldehyde is an aromatic compound found in buckwheat, chocolate and many other foods and flowers.It is also responsible for the antibiotic activity of maggot therapy and it is also a compound that is added to cigarettes to improve their aroma....

, calcium carbonate
Calcium carbonate
Calcium carbonate is a chemical compound with the formula CaCO3. It is a common substance found in rocks in all parts of the world, and is the main component of shells of marine organisms, snails, coal balls, pearls, and eggshells. Calcium carbonate is the active ingredient in agricultural lime,...

, and proteolytic enzymes. Bacteria not killed by these secretions are subsequently ingested and lysed
Lysis
Lysis refers to the breaking down of a cell, often by viral, enzymic, or osmotic mechanisms that compromise its integrity. A fluid containing the contents of lysed cells is called a "lysate"....

 within the maggots.

In vitro
In vitro
In vitro refers to studies in experimental biology that are conducted using components of an organism that have been isolated from their usual biological context in order to permit a more detailed or more convenient analysis than can be done with whole organisms. Colloquially, these experiments...

studies have shown that maggots inhibit and destroy a wide range of pathogenic bacteria including methicillin-resistant Staphylococcus aureus (MRSA), group A and B streptococci, and Gram-positive aerobic and anaerobic strains. Other bacteria like Pseudomonas aeruginosa, E.coli or Proteus spec are not attacked by maggots and in case of Pseudomonas even the maggots are in danger. Therefore, using maggots alone might lead to a change of bacteria flora on the wound. Maggot therapy therefore represents a cost-effective method for managing MRSA infection.

Wound healing


Maggot therapy has been shown by multiple researchers to have wound healing properties. Maggot secretions appear to amplify the wound healing effects of host epidermal growth factor
Epidermal growth factor
Epidermal growth factor or EGF is a growth factor that plays an important role in the regulation of cell growth, proliferation, and differentiation by binding to its receptor EGFR...

 (EGF) and IL-6
Interleukin 6
Interleukin-6 is a protein that in humans is encoded by the IL6 gene.IL-6 is an interleukin that acts as both a pro-inflammatory and anti-inflammatory cytokine. It is secreted by T cells and macrophages to stimulate immune response, e.g. during infection and after trauma, especially burns or other...

. Recent studies have shown that maggot secretions are able to stimulate the growth of human fibroblast
Fibroblast
A fibroblast is a type of cell that synthesizes the extracellular matrix and collagen, the structural framework for animal tissues, and plays a critical role in wound healing...

s and slow-growing chondrocyte
Chondrocyte
Chondrocytes are the only cells found in cartilage. They produce and maintain the cartilaginous matrix, which consists mainly of collagen and proteoglycans...

s. Chondrocyte proliferation, as well as the synthesis of cartilage-specific type II collagen, increases in the maggot secretion environment. Micromassage of the wound by maggot movement is further thought to stimulate the formation of granulation tissue and wound exudates by the host. The precise mechanism(s) of maggot stimulation of wound healing is an active area of study by several researchers including Dr. Ronald Sherman. The by far biggest clinical study shows, that healing cannot be expected by maggots.

Maggot secretions also contain a substance called allantoin
Allantoin
Allantoin is a chemical compound with formula C4H6N4O3. It is also called 5-ureidohydantoin or glyoxyldiureide. It is a diureide of glyoxylic acid....

 (also found in many shaving gels) which has a soothing effect on the skin. Some patients with leg ulcers with a significant arterial component complain that their wounds become more painful on the second or third day of maggot therapy.

Limitations


The wound must be of a type which can actually benefit from the application of maggot therapy. A moist, exudating wound with sufficient oxygen supply is a prerequisite. Not all wound-types are suitable: wounds which are dry, or open wounds of body cavities do not provide a good environment for maggots to feed. In some cases it may be possible to make a dry wound suitable for larval therapy by moistening it with saline
Saline (medicine)
In medicine, saline is a general term referring to a sterile solution of sodium chloride in water but is only sterile when it is to be placed intravenously, otherwise, a saline solution is a salt water solution...

 soaks, applied for 48 hours.

Maggots have a short shelf life
Shelf life
Shelf life is the length of time that food, drink, medicine, chemicals, and many other perishable items are given before they are considered unsuitable for sale, use, or consumption...

 which prevents long term storage before use. Patients and doctors may find maggots distasteful, although studies have shown that this does not cause patients to refuse the offer of maggot therapy. Maggots can be enclosed in opaque polymer bags to hide them from sight. Dressings must be designed to prevent any maggots from escaping, while allowing air to get to the maggots. Dressings are also designed to minimize the uncomfortable tickling sensation that the maggots often cause.

Comparative studies


In 2008, a scientific study published in the British Medical Journal
British Medical Journal
BMJ is a partially open-access peer-reviewed medical journal. Originally called the British Medical Journal, the title was officially shortened to BMJ in 1988. The journal is published by the BMJ Group, a wholly owned subsidiary of the British Medical Association...

 compared the merits of maggot therapy and standard hydrogels to treat 270 British patients with leg ulcers from around the UK. Patients were treated with either maggots or hydrogel and their progress followed for up to a year.

The study revealed no significant differences in the time taken for the ulcer to heal, or in the patient's quality of life. Maggots were shown to be no more effective than hydrogel treatment at reducing the amount of bacteria present or in clearing MRSA. Although maggots were significantly more efficient at debridement of the wound, treatment with maggots was associated with more pain by patients. A separate study which compared the relative cost-effectiveness of maggot therapy with hydrogels estimated there was little to choose between the two therapies.

Biology of flies and maggots used in maggot therapy



Maggots are fly larvae, or immature flies, just as caterpillars are butterfly or moth larvae.
Not all species of flies are safe and effective as medicinal maggots. There are thousands of species of flies, each with its own habits and life cycle. Some fly larvae feed on plants or animals, or even blood. Others feed on rotting organic material.

Those flies whose larvae feed on dead animals will sometimes lay their eggs on the dead parts (necrotic or gangrenous tissue) of living animals. The infestation by maggots of live animals is called “myiasis
Myiasis
Myiasis is a general term for infection by parasitic fly larvae feeding on the host's necrotic or living tissue. Colloquialisms for myiasis include flystrike, blowfly strike, and fly-blown. In Greek, "myia" means fly....

.” Some maggots will feed only on dead tissue, some only on live tissue, and some on live or dead tissue. The flies used most often for the purpose of maggot therapy are "blow flies" (Calliphoridae); and the species used most commonly is Phaenicia sericata, the green blow fly. Another important species, Protophormia terraenovae
Protophormia terraenovae
Protophormia terraenovae is commonly called northern blowfly, blue-bottle fly or blue-assed fly. It is distinguished by its deep blue coloration and large size, is an important species throughout the northern hemisphere. This fly is notable for its economic impact as a myiasis pest of livestock...

, is also notable for its feeding secretions, which combat infection by Streptococcus pyogenes
Streptococcus pyogenes
Streptococcus pyogenes is a spherical, Gram-positive bacterium that is the cause of group A streptococcal infections. S. pyogenes displays streptococcal group A antigen on its cell wall. S...

and Streptococcus pneumoniae
Streptococcus pneumoniae
Streptococcus pneumoniae, or pneumococcus, is Gram-positive, alpha-hemolytic, aerotolerant anaerobic member of the genus Streptococcus. A significant human pathogenic bacterium, S...

.

In popular culture


In a scene set in 1809, the wound of Lt. Sharpe
Richard Sharpe (fictional character)
Sharpe is a series of historical fiction stories by Bernard Cornwell centred on the character of Richard Sharpe. The stories formed the basis for an ITV television series wherein the eponymous character was played by Sean Bean....

 (Sean Bean
Sean Bean
Shaun Mark "Sean" Bean is an English film and stage actor. Bean is best known for playing Boromir in The Lord of the Rings Trilogy and, previously, British Colonel Richard Sharpe in the ITV television series Sharpe...

) is left clean by applied maggots in the 1993 TV programme Sharpe's Eagle
Sharpe's Eagle (TV programme)
Sharpe's Eagle is the second in the series of Sharpe television dramas, based on the novel of the same name. Shown on ITV in 1993, the adaptation stars Sean Bean, Daragh O'Malley and Assumpta Serna.-Plot summary:...

. Rather than being merely discussed, the maggots are shown on the skin around the wound. In the 2000 film Gladiator
Gladiator (2000 film)
Gladiator is a 2000 historical epic film directed by Ridley Scott, starring Russell Crowe, Joaquin Phoenix, Connie Nielsen, Ralf Möller, Oliver Reed, Djimon Hounsou, Derek Jacobi, John Shrapnel and Richard Harris. Crowe portrays the loyal Roman General Maximus Decimus Meridius, who is betrayed...

, Russell Crowe
Russell Crowe
Russell Ira Crowe is a New Zealander Australian actor , film producer and musician. He came to international attention for his role as Roman General Maximus Decimus Meridius in the 2000 historical epic film Gladiator, directed by Ridley Scott, for which he won an Academy Award for Best Actor, a...

's character has a shoulder wound cleaned with maggots.

In the Roman Mysteries series maggots were used on an injury as an alternative to amputation. In the story the therapy was successful and the man was able to walk again.

In addition, the television show House, M.D.
House (TV series)
House is an American television medical drama that debuted on the Fox network on November 16, 2004. The show's central character is Dr. Gregory House , an unconventional and misanthropic medical genius who heads a team of diagnosticians at the fictional Princeton-Plainsboro Teaching Hospital in...

 included treatment of a burn by maggot therapy in the twelfth episode of the second season, titled "Distractions," on February 14, 2006.

Claire Frazier, a medical practitioner and principal character in Diana Gabaldon's Outlander
Outlander
Outlander may refer to:*Outlander , a 2008 film, directed by Howard McCain and starring James Caviezel*Outlander , a 1991 novel by Diana Gabaldon*Mitsubishi Outlander, a compact SUV...

 series of novels, often uses maggots for debridement of necrotic tissue in her patients' wounds.

The titular character of Johnny Got His Gun
Johnny Got His Gun
Johnny Got His Gun is an anti-war novel written in 1938 by American novelist and screenwriter Dalton Trumboand published by J. B. Lippincott company.-Plot:...

claims that maggot therapy could have prevented his quadruple amputations.

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