Maggot therapy

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Lucilia maggots in a cleaned wound
Goldfly - genus Lucilia

In maggot therapy (also known as larval therapy or biosurgery ), disinfected maggots grown in special laboratories are used to rid chronic wounds of dead ( necrotic ) tissue and bacterial contamination. The maggots of the golden fly ( Lucilia sericata ) are mainly used. The larvae of this species feed on dead tissue, they have no teeth and do not bite. However, their secretions can also damage healthy tissue.

The maggots of the gold fly have an extracorporeal pre-digestion ( extraintestinal digestion ); so they release digestive juices to liquefy the food that is then ingested. They are used either as "free runners", that is, they are freely movable in the wound, or in a gauze bag that is placed on the wound. The digestive juices are released into the wound and the thickened, liquefied tissue is then taken up through the gauze. The use of maggots in bags, however, significantly reduces the effect.

history

Until the 19th century

Petri dish with Lucilia larvae

There are reports of several peoples using maggots to clean wounds. These include the Ngemba, an Aboriginal tribe in New South Wales , peoples in northern Burma as far as the Chinese province of Yunnan and the Maya , who only put cloths soaked with animal blood in the sun and, after flies have laid their eggs on them, on the wounds should have laid.

Since the 17th century there have been sporadic reports in Europe of the benefit of fly larvae in wound healing, for example by Hieronymus Fabricius (1537-1619), Ambroise Paré (1510-1590) and in 1829 by Dominique Jean Larrey . Larrey, a field doctor in the French Army, was unable to convince his patients to leave the maggots in their wounds. During the American Civil War , the military doctor John Forney Zacharias used fly maggots specifically to treat gangrene . Zacharias stated that the treatment resulted in quick and effective wound healing and a higher survival rate for the wounded.

During this war, other field doctors also noticed the beneficial effects of infesting the wound. However, there was no more widespread targeted application. Maggot therapy is still recommended by military doctors today when no alternatives are available. However, if pain occurs, soldiers are also recommended to discontinue the treatment in order not to lose healthy tissue.

The New World screwworm fly ( Cochliomyia hominivorax ), whose larvae consume living tissue.

One of the problems that arose was the correct assignment of the larvae to different fly species, especially in the case of unexpected maggot infestation. There are those who actively bury themselves in living tissue and thereby damage it, such as the New World screwworm fly ( Cochliomyia hominivorax ). One then speaks of myiasis , the fly maggot disease. In contrast, the larva of the gold fly Lucilia sericata cannot cling to smooth human skin, it needs a fur to help and therefore only affects small animals such as rabbits or sheep. To protect the latter from this, amputation of the sheep's tail ( mulesing ) was outlawed. The Blowfly Strike , the fatal attack by Lucilia fly maggots on sheep, is feared in sheep-farming countries. In addition, the germ theory was developed at the end of the 19th century and it was recognized that flies can transmit pathogens (see below).

Early 20th century

Also in the 20th century the positive effects of fly maggots were first noticeable during the war when the medical supply situation was poor. The death rate for open, infected wounds was over 70%. The American surgeon Wiliam S. Baer was a field doctor in France during the First World War . He later reported that he treated two soldiers who had been wounded on a battlefield for seven days and had thousands of fly maggots in their wounds. After Baer removed them, he found the wounds to be clean and healing surprisingly quickly and without complications .

In 1929 Baer was professor of orthopedic surgery at Johns Hopkins University in Baltimore , Maryland . Here he looked for therapies for patients with osteomyelitis (inflammation of the bone marrow), including many children. In 21 patients with chronic osteomyelitis that had previously been therapy-resistant, Baer inserted maggots from a local blowfly into the opened lesions every four days for several weeks . After two months, all 21 patients could be discharged as cured.

Phormia regina was offered by pharmaceutical companies for wound healing.

A problem with further use was the contamination of the maggots with Clostridium tetani , the causative agent of tetanus , and Clostridium perfringens , the most common pathogen causing gas fire . In order to obtain sterile cultures, he sterilized eggs and then added them to sterilized feed until they reached the desired size. Surgical maggots of the species Lucilia sericata and Phormia regina were eventually offered by pharmaceutical companies. Between 1930 and 1940 over a hundred medical-scientific publications on maggot therapy were published. Maggot therapy has been used in practice in over 300 American hospitals.

With the introduction of sulfonamides and penicillin , other means of wound treatment suddenly became available and progress in maggot therapy came to a standstill. Between 1940 and 1990 only a few articles appeared describing how maggot therapy was used as the last exotic treatment for hopeless cases. In 1988 maggot therapy was declared dead by microbiologist Milton Wainwright :

"Fortunately maggot therapy is now relegated to a historical backwater, of interest more for its bizarre nature than its effect on the course of medical science ... a therapy the demise of which no one is likely to mourn."

Fortunately, maggot therapy is now relegated to historical spheres, of interest more because of its bizarre nature than because of its influence on medical science. ... A therapy whose passing nobody will regret. "

- Milton Wainwright

Resurgence since the 1990s

Size comparison: right, two days after hatching - left five days after hatching

In the late 1980s, Ronald Sherman and Edward Pechter, doctors at the Medical Center of the University of California, Los Angeles , examined a wound that happened to be infected with maggots in a patient and observed how clean it was. Sherman then set up a fly breeding facility at the Veterans Administration Hospital in Long Beach, California , to produce sterile maggots that were used to treat wounds. First studies in the 1990s showed faster breakdown of necrotic tissue than other methods.

In 1995, the first European production facility for goldfly larvae was set up in Wales . ZooBiotic delivered over 5,000 units to hospitals and resident doctors within three years. In Germany only the Biomonde company is still active as a manufacturer and distributor of fly maggots. Biomonde was acquired by ZooBiotic on May 4, 2010. In 2002 over 1,000 clinics, hospitals and medical practices used maggot therapy. Biomonde larval products have been approved as finished medicinal products in Germany since February 2014.

The effectiveness of maggot therapy against wound infections - for example in postoperative wound treatment - was recognized in 2004 by the Food and Drug Administration ( FDA ), the American drug approval authority.

Effect and application

Larvae of Lucilia sericata for maggot therapy in a gauze bag (BioBag)

Breakdown of necrotic wound coverings

Many chronic wounds are covered with a covering of dead cells and wound exudate . These coverings hinder wound observation and assessment and also wound healing, since on the one hand they represent a mechanical obstacle in wound treatment and on the other hand they are cut off from the bloodstream and thus from the body's own immune system . The wound coverings are ideal breeding grounds for bacteria, which in turn impede wound healing. The bacterial infestation can cause a form of tissue necrosis called gangrene , and in extreme cases multi-organ failure can occur if toxic or immunosuppressive (immune-suppressing) substances enter the bloodstream from the border zone between necrotic and intact tissue .

Since the gold fly maggots feed on necrotic material, the wound coverings represent an ideal source of food for them. The gold fly larvae are applied to the wound to be treated and excrete digestive juices there. The enzymes it contains digest the tissue and liquefy it. The resulting mixture is absorbed and digested by the gold fly maggots. The gold fly maggots gain 100 times their weight in just a few days. Then they stop feeding and have to be replaced by new, newly hatched golden fly maggots with a corresponding appetite. After several applications, a wound is left free of the necrotic wound coating, which can then be treated further. Accelerated wound healing is not to be expected from wound cleaning.

Selective bactericidal effect

Maggot therapy for an infected wound in diabetic foot syndrome
Made by Lucilia .

The golden fly maggots eliminate bacteria by producing their own group of antibacterial substances ( defensins ) and seraticin , and by excreting ammonia and ammonia derivatives, raising the pH value in the wound to a level that is not well tolerated by bacteria. Then the killed bacteria are sucked up and digested together with the digested, dead tissue. It is irrelevant whether the bacteria are resistant to individual antibiotics or even have multi- resistance. For this reason, maggot therapy is also used for wounds that are infected with MRSA strains or other multi-resistant bacteria. An overview of the ingredients of the maggots and their effects can be found in the book "Nature helps ..." by the parasitologist Heinz Mehlhorn .

A laboratory study found that Lucilia sericata larvae are sensitive to Pseudomonas aeruginosa bacteria and can die. So you will not be able to get rid of all the bacteria that may be found in wounds.

Side effects

About 20 to 35 percent of patients with wounds feel additional pain and need pain relievers ( analgesics ). The cause is the build-up of the non-necrotic wound edges.

Application examples

In addition to inflammation of the bone marrow ( osteomyelitis ) and diabetic gangrene , in which tissue dies, maggot therapy is also used for lower leg ulcers ( ulcus cruris ) and inflammatory pressure points ( decubitus ).

Comparison with other methods

A randomized study from 2009 on 267 patients with an ulcus cruris ( open leg ) compared maggot therapy with Lucilia sericata and a conventional therapy in which a hydrogel was applied. Dead tissue was broken down more quickly with maggot therapy ( debridement ; two to three instead of ten weeks), but the duration of wound healing was not significantly different; the median value was around 240 days in each case. This applied regardless of whether the maggots were exposed to the wound or in a gauze net . Maggot therapy patients had significantly more wound pain towards the end of the first application of the maggot. The costs incurred were comparable. The authors of the study therefore recommend considering the patient's wishes and their experience of pain with the maggots when deciding on a therapy.

Types of fly used

Lucilia sericata has been by far the most widely used since Baer's 1931 study. The use of other Calliphoridae species has been described in only four ( Phormia regina ), two ( Lucilia caesar ) or one study ( Calliphora vicina , Chiysomya rufifacies . Lucilia caesar , Lucilia cuprina , Lucilia ilhatris , Protophormia terraenovae ). The Sarcophagidae species Wohlfahrtia nuba was also usedin a study.

As of 2009, a certain breeding line (strain LB-01) of the species Lucilia sericata is approved for sale in the USA .

literature

  • Frank L. Bowling, Eleanna V. Salgami, Andrew J. Boulton: Larval therapy: a novel treatment in eliminating methicillin-resistant Staphylococcus aureus from diabetic foot ulcers. In: Diabetes care . Volume 30, Number 2, February 2007, pp. 370-371, ISSN  0149-5992 . doi: 10.2337 / dc06-2348 . PMID 17259512 .
  • Wim Fleischmann, Martin Grassberger, Ronald Sherman: Maggot Therapy: A Handbook of Maggot-Assisted Wound Healing . Thieme Verlag, 2004, ISBN 1-58890-232-3 .
  • Wim Fleischmann, Martin Grassberger: Successful wound healing through maggot therapy . Haug Fachbuchverlag, 2002, ISBN 3-8304-3011-6 .
  • Martin Grassberger, C. Frank: Wound healing by sterile fly larvae: mechanical, biochemical and microbiological principles. In: Wiener medical Wochenschrift (1946). Volume 153, Numbers 9-10, 2003, pp. 198-201, ISSN  0043-5341 . PMID 12836455 . (Review).
  • Michael Schmidt: Maggot therapy instead of amputation . In: PTA Today . No. 23, 2009, werner-sellmer.de (PDF)

Web links

Wiktionary: Maggot therapy  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. Jump up ↑ Wim Fleischmann, M. Russ, D. Moch, Christoph Marquardt: Biosurgery - maggots, are they really the better surgeons? Surgeon. 1999 Nov; 70 (11): 1340-6. PMID 10591775 .
  2. ↑ Finn Gottrup, Bo Jørgensen: Maggot debridement: An Alternative Method for debridement . In: Open Science Company (Ed.): Eplasty . 11, no. E33, 2011. PMC 3136394 (free full text).
  3. ^ R. Strohal, J. Dissemond, J. Jordan O'Brien, A. Piaggesi, R. Rimdeika, T. Young and J. Apelqvist: EWMA document: Debridement - An updated overview and clarification of the principle role of debridement Archived from Original on February 10, 2015. Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. In: Anthony Kerr (Ed.): Journal of Wound Care . 22, No. 1, 2013, pp. 1-49. Retrieved June 23, 2015. @1@ 2Template: Webachiv / IABot / ewma.org
  4. ↑ Glod, A. (2014): Debridement with fly larvae. In: ProVita, Mühlen Verlag, issue 02/2014, pp. 13-16.
  5. ↑ a b Heike Elfriede Heuer et al .: Wound Pain in Larval Therapy (English). In the British Medical Journal of March 7, 2011. Retrieved June 25, 2011.
  6. ↑ Thomas S, Wynn K, Fowler T, Jones M: The effect of containment on the properties of sterile maggots . In: Br J Nurs . 11, No. 12 Suppl, June 2002, pp. S21-2, S24, S26 passim. PMID 12131859 .
  7. ↑ a b c d e f g h Martin Grassberger: A historical review of the therapeutic use of fly larvae . In: NTM Journal for the History of Science, Technology and Medicine . tape 10 , no. 1–3 , 2002, pp. 13-24 , doi : 10.1007 / BF03033095 .
  8. ^ Robert Scott Root-Bernstein, Michele Root-Bernstein: Honey, Mud, Maggots and Other Medical Marvels: Science Behind Folk Remedies and Old Wives' Tales . 2000, ISBN 0-330-37378-1 .
  9. ↑ United States Army Institute for Military Assistance (Ed.): ST31-91B US Army Special Forces Medical Handbook . 1982, Chapter 22 ( fas.org [PDF; 5,7 MB ]).
  10. ↑ Fiona Smith: Are my rabbits in danger from flies?  ( Page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.@1@ 2Template: Dead Link / www.hertfordshiremercury.co.uk  
  11. ↑ Yamni Nigam, Edward Dudley, Alyson Bexfield, A.Elizabeth Bond, Julie Evans, Jane James: The Physiology of Wound Healing by the Medicinal Maggot, Lucilia sericata . In: Advances in insect physiology . 39, 2010, pp. 39-81. doi : 10.1016 / B978-0-12-381387-9.00002-6 .
  12. ↑ Milton Wainwright: Maggot Therapy. A Backwater in the Fight Against Bacterial Infection . In: Pharmacy in History . 30, No. 1, 1988, pp. 19-26. PMID 11612403 .
  13. ↑ a b Monarch Labs and Maggot Therapy . Monarchlabs.com. Retrieved June 6, 2010.
  14. ↑ ZooBiotic BioSurgical Products for the Treatment of Chronic Wounds Infected and necrotic . Zoobiotic.co.uk. Archived from the original on October 11, 2010. Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved June 6, 2010. @1@ 2Template: Webachiv / IABot / www.zoobiotic.co.uk
  15. ^ The World's Smallest "Surgeons" . Health in Wales. Retrieved November 6, 2010.
  16. ↑ a b current information on therapy with fly larvae (maggots) . Werner-sellmer.de. Archived from the original on June 29, 2012. Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved June 6, 2010. @1@ 2Template: Webachiv / IABot / www.werner-sellmer.de
  17. ↑ Chris Löwer: Search for the secret of animal therapy In: Spiegel-online , July 22, 2007, accessed on July 11, 2017.
  18. ↑ JC Dumville, G. Worthy, JM Bland, N. Cullum, C. Dowson, C. Iglesias, JL Mitchell, EA Nelson, MO Soares, DJ Torgerson: Larval therapy for leg ulcers (VenUS II): randomized controlled trial. In: BMJ (Clinical research ed.). Volume 338, 2009, p. B773, ISSN  1468-5833 . PMID 19304577 . PMC 2659858 (free full text).
  19. ↑ Heike and Lutz Heuer: Blowfly strike and maggot therapy. In: Heinz Mehlhorn: Nature Helps ...: How Plants and Other Organisms Contribute to Solve Health Problems . Springer Science & Business Media, June 15, 2011, ISBN 978-3-642-19382-8 , pp. 315-7.
  20. ↑ AS Andersen, B Joergensen, T Bjarnsholt, H Johansen, T Karlsmark, M Givskov, KA Krogfelt: Quorum-sensing-regulated virulence factors in Pseudomonas aeruginosa are toxic to Lucilia sericata maggots . In: Microbiology (Reading, Engl.) . 156, No. Pt 2, February 2010, pp. 400-7. doi : 10.1099 / mic.0.032730-0 . PMID 19892758 . PMC 2885677 (free full text).
  21. ↑ KY Mumcuoglu: Clinical applications for maggots in wound care. In: American Journal of Clinical Dermatology , 2001, 2 (4), pp. 219-227, PMID 11705249 .
  22. ↑ Leg ulcer: Disenchantment of maggot therapy . ( Memento of the original from April 10, 2011 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. In: Deutsches Ärzteblatt, March 20, 2009; Retrieved April 26, 2015. @1@ 2Template: Webachiv / IABot / www.aerzteblatt.de
  23. ↑ JC Dumville, G Worthy, JM Bland, N Cullum, C Dowson, C Iglesias, JL Mitchell, EA Nelson, MO Soares, DJ Torgerson: Larval therapy for leg ulcers (VenUS II): randomized controlled trial . In: BMJ . 338, 2009, p. B773. PMID 19304577 . PMC 2659858 (free full text).
  24. ^ MO Soares, CP Iglesias, JM Bland, N Cullum, JC Dumville, EA Nelson, DJ Torgerson, G Worthy: Cost effectiveness analysis of larval therapy for leg ulcers . In: BMJ . 338, 2009, p. B825. PMID 19304578 . PMC 2659856 (free full text).
  25. ↑ Martin Grassberger: Fly Maggots: Parasites and wound healers . In: Denisia 6 . tape 6 , 2002, pp. 507-534 ( PDF on ZOBODAT ).
  26. ↑ Sherman RA: Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century . In: J Diabetes Sci Technol . 3, No. 2, March 2009, pp. 336-44. PMID 20144365 . PMC 2771513 (free full text).
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