Maggot Debridement Therapy in Necrotizing Fasciitis

Maggot Debridement Therapy in Necrotizing Fasciitis

        Figure 1.

        After debridement and fasciectomy of th...
Maggot Debridement Therapy in Necrotizing Fasciitis

        to prevent maggot escape.

        Figure 3.

Maggot Debridement Therapy in Necrotizing Fasciitis

prevents maggot death from dehydration. Every 3 to 4 days new contai...
Maggot Debridement Therapy in Necrotizing Fasciitis

In-vitro and in-vivo investigations have shown that sterile maggots...
Maggot Debridement Therapy in Necrotizing Fasciitis

Table 2. Summary of Patient and Treatment Characteristics of 15 Pa...
Maggot Debridement Therapy in Necrotizing Fasciitis


   1. Wong CH, Wang YS. The diagnosis of necrotizing f...
Maggot Debridement Therapy in Necrotizing Fasciitis

  14. Wollina U, Karte K, Herold C, Looks A. Biosurgery i...
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Fournier gangrene ii


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Fournier gangrene ii

  1. 1. Maggot Debridement Therapy in Necrotizing Fasciitis www.medscape. com To Print: Click your browser's PRINT button. NOTE: To view the article with Web enhancements, go to: Maggot Debridement Therapy in Necrotizing Fasciitis Reduces the Number of Surgical Debridements Pascal Steenvoorde, MD, MSc;1 Cathrien Jacobi, PhD;2 Chun Wong;3 Gerrolt Jukema, MD, PhD3 Wounds. 2007;19(3):73-78. ©2007 Health Management Publications, Inc. Posted 05/09/2007 Abstract and Case Report Abstract Necrotizing fasciitis is a rare but potentially lethal bacterial infection of the fascial and subcutaneous tissues. Mortality rates of this condition remain high, ranging from 6%-76%.[1] Bacterial cultures may show a wide variety of organisms,[2] but Group A Streptococcus (Streptococcus pyogenes) is the causative agent in up to 71% of all human cases.[3,4] The treatment consists of urgent radical surgical debridement in combination with broad-spectrum antibiotic therapy. [5] Maggot debridement therapy (MDT) has been proven to be very effective in the treatment of gram-positive bacterial infections.[6-9] The present study reports on the results of 15 patients with necrotizing fasciitis treated with surgical debridement and antibiotic therapy in combination with MDT from November 2001 to November 2005. A detailed case report of 1 patient is presented. Case Report 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 CiprofloxacinAE 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. (1 of 8) [12/06/2007 2:28:28]
  2. 2. Maggot Debridement Therapy in Necrotizing Fasciitis Figure 1. After debridement and fasciectomy of the abdominal fascia, perineum, and scrotal fascia. 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 (VitapadAE, 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). Figure 2. The biobags (Vitapads®) are placed on the wound. The wound edges are secured with an adhesive tape in order (2 of 8) [12/06/2007 2:28:28]
  3. 3. Maggot Debridement Therapy in Necrotizing Fasciitis to prevent maggot escape. Figure 3. Post-operative end-result after 1 year; the wound fully healed after mesh grafting. Methods 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 (3 of 8) [12/06/2007 2:28:28]
  4. 4. Maggot Debridement Therapy in Necrotizing Fasciitis 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 SPSS99 version 12.0.1 for WindowsAE 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. Results From November 2001 to December 2005 a total of 15 patients with necrotizing fasciitis were treated in the authors' hospital with a combination of surgical debridement, antibiotic therapy, and MDT ( Table 1 ). After diagnosis, all patients received broad-spectrum antibiotic therapy, which was changed according to the antibiogram. All patients were treated with surgical debridement after a clinical diagnosis of necrotizing fasciitis. There were 10 men (67%) and 5 women (33%) treated ( Table 2 ). Ages ranged from 18-79 years with an average age of 51 years. The necrotizing fasciitis was located in the groin area (n = 6; 40%), upper leg (n = 3; 20%), arm (n = 3; 20%), abdomen (n = 2; 13%), and head/neck region (n = 1; 7%). Three patients were diagnosed with Fournier's gangrene (20%). The patients needed an average of 2.9 debridements (range 1-6). In 5 of the 15 patients, Streptococcus pyogenes was the sole causative agent. Two patients (13%) died, 1 from cardiogenic shock, and the other due to metastasis of a primary urothelial cell carcinoma. Both deaths were not due to postponed surgical debridement. An average of 45 biobags per patient (range 9-100 bags) were needed. The MDT period was on average 17 days (range 3-38 days). The patients were split into an "early treated" group (within 9 days after diagnosis; n = 8), and a "late treated" group (more than 9 days after diagnosis; n = 7), because the median number of days to MDT start after diagnosis was 9 days. This was done to gain insight at to the effect early application of maggots in necrotizing fasciitis might have on improving patient prognosis. There were no statistical significant differences in outcomes between the early- and late- treated groups; although, the early treated group had a shorter ICU stay (4 days versus 29 days; P = 0.213) and a shorter total hospital stay (30 days versus 59 days; P = 0.094). The number of surgical debridements was less and statistically significant in the patients where maggots were applied within 9 days after diagnosis (1.8 versus 4.1 surgical debridements; P = 0.001). Excluding the 2 patients who died, the wounds eventually healed either by secondary intention or surgical closure in all of the patients. Secondary closure was performed on average after 10 days (range 0-21 days), and mesh graft at 19 days (range 0-39 days) after the end of MDT. Discussion Fifteen patients with necrotizing fasciitis are described in whom treatment consisted of surgical debridement and antibiotic therapy, as well as treatment with sterile maggots. This study showed that in most cases, this potentially lethal condition was successfully treated with this technique. Necrotizing fasciitis can affect any part of the body but the extremities, the perineum, and the truncal areas are most commonly involved.[11] In this study, most patients (40%) had necrotizing fasciitis of the groin area. Mortality rates for necrotizing fasciitis reported in the literature range from 6%-76%; mortality rates are significantly increased if operative debridement is delayed.[1] Failure to recognize and diagnose necrotizing fasciitis possibly contributes to the high mortality rate.[12] Diagnosis of this disease remains a clinical one—severe pain disproportionate to local findings in association with systemic toxicity should raise suspicion.11 More than 75 years ago, MDT was used in a clinical hospital setting for the treatment of osteomyelitis.[13] More recently, MDT has proven to be a valuable treatment option for various indications. In 2000, Wollina et al[14] described indications for MDT— fasciitis necroticans was not separately mentioned. Frequent indications reported in the literature are for treating leg ulcers and pressure sores.[15-20,27] Nigam et al[21] recently published an article discussing evidence supporting the potent antibacterial action of maggot secretions. Aside from debridement and disinfection, a third important factor of MDT is discussed: enhanced healing.[21] Although success rates for MDT reported in literature vary, 80% is the closest estimated percentage.[22] (4 of 8) [12/06/2007 2:28:28]
  5. 5. Maggot Debridement Therapy in Necrotizing Fasciitis In-vitro and in-vivo investigations have shown that sterile maggots (larvae of Lucilia sericata) are especially capable in the treatment of infected wounds with gram-positive bacteria.[9] Necrotizing fasciitis, which is mainly caused by gram-positive bacteria, seems to be an ideal indication for MDT.[6-9] Urgent, radical surgical debridement in combination with broad-spectrum antibiotic therapy is necessary after necrotizing fasciitis has been diagnosed.[5] In the authors' experience, repeated debridements are needed. The only reports of necrotizing fasciitis treated with maggots have been seen in case reports. Two of the 15 herein reported patients have been reported earlier—1 patient with a Fournier's gangrene23 and 1 patient with necrotizing fasciitis after a pelvic fracture.[24] Successful debridement with MDT of fasciitis of the head and neck25 and Fournier's gangrene26 have been described recently. The literature debates that MDT is contraindicated in cases of rapidly advancing infections, such as necrotizing fasciitis.[27,28] The authors disagree, although would stress that the first debridement in a case of necrotizing fasciitis should always be surgical. Only after administration of broad- spectrum antibiotic therapy and surgical debridement can maggots be placed on the wound as an additional treatment method, not as the sole treatment. This patient series showed that relatively early application of maggots reduced the number of surgical debridements. In the early treated group the number of surgical debridements was considerably lower in comparison to the late treated group (1.8 versus 4.1; P = 0.001). This means that the use of maggots reduced the necessity to go back to the operating room to perform surgical debridement. It is important that healthcare professionals and patients realize that MDT is not the only wound treatment available for necrotizing fasciitis. After adequate debridement and disinfection, other treatments are sometimes necessary before wound closure can be achieved. Vacuum assisted closure (V.A.C. AE Therapy, KCI, San Antonio, Tex) is a potent wound therapy to stimulate further granulation tissue. In cases of necrotizing fasciitis, vacuum-assisted closure has proven its value.[24,29,30] A reduction in the number of surgical debridements could lower the mortality rates associated with necrotizing fasciitis. Furthermore, the cosmetic and functional outcome might be improved because the number of surgical procedures is reduced. This is because maggots are able to distinguish between viable- and nonviable tissue more effectively than a surgeon. Caution should be taken before definitively concluding that MDT replace surgical debridement altogether, which cannot be concluded from a retrospective case series. Table 1. Necrotizing fasciitis: characteristics of Patients Treated with Maggot Debridement Therapy. (5 of 8) [12/06/2007 2:28:28]
  6. 6. Maggot Debridement Therapy in Necrotizing Fasciitis Table 2. Summary of Patient and Treatment Characteristics of 15 Patients who Presented with Necrotizing Fasciitis and were Treated with Maggot Debridement Therapy. (6 of 8) [12/06/2007 2:28:28]
  7. 7. Maggot Debridement Therapy in Necrotizing Fasciitis References 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- (7 of 8) [12/06/2007 2:28:28]
  8. 8. Maggot Debridement Therapy in Necrotizing Fasciitis 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: 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. Reprint Address Address correspondence to: Pascal Steenvoorde, MD, MSc Rijnland Hospital Leiderdorp Simon Smitweg 1 Leiderdorp, The Netherlands Phone: 0031-715-828282 E-mail: Pascal Steenvoorde, MD, MSc,1 Cathrien Jacobi, PhD,2 Chun Wong,3 and Gerrolt Jukema, MD, PhD3 1Department of Surgery, Rijnland Hospital, Leiderdorp, The Netherlands 2Department of Medical Decision Making 3Department of Traumatology, Leiden University Medical Center, The Netherlands (8 of 8) [12/06/2007 2:28:28]