We explain how we used medical grade maggot in the debridement of non-healing wounds in developing country and resource poor setting

1. Maggot Debridement Therapy: Experience from
Aminu Kano Teaching Hospital, Kano,
Northwestern Nigeria
Dr. Mustapha A. Yusuf
MBBS, MSc, PGDE, PhD (Medical Entomology)
Assistant Professor/Honourary Consultant
BUK/AKTH
1

2. Outline
OVERVIEW OF MAGGOT THERAPY
• Introduction
• History
• Current Status
• Wounds for MDT
• Mechanism
• Studies
• Patients Perception
• Conclusion
2

3. • In spite of the significant technological advances that have been made in
surgery and wound care management, wound infection and associated
complications remain a serious challenge in healthcare delivery system.
• Chronic wounds remain a great source of stress to patients, nurses,
clinicians and the healthcare systems worldwide.
3
Introduction 1

4. Introduction 2
• It represent a high percentage of healthcare costs both in developed
and developing nations of the world including Nigeria.
• The increasing rate of antibiotic-resistant strains of healthcare
associated bacteria pathogens and the need for alternative effective
non-surgical methods of wound debridement has led to the re-
introduction of maggot therapy
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5. • Maggot therapy is an emerging procedure that involves applying sterile
maggots of Dipteran species (commonly Lucilia sericata) to initiate and
effect debridement, disinfection and promote healing in wounds refractory
to antimicrobial treatment.
5
Introduction 3

6. History of MDT 1
• During the Crimean War (1853-1856) Nikolay Pirogov, a Russian
surgeon used MDT in the battle field where the technique saved many
soldier’s lives.
• Johns Hopkins Professor of Orthopaedics, William Baer was the first
who treated, studied, and published a sizeable series of patients into
whose wounds he applied larvae.
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7. History of MDT 2
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‘’During my service in the hospital in Danville, Virginia, I first used larvae to
remove the decayed tissue in hospital gangrene and with eminent
satisfaction. In a single day they would clean a wound much better than any
agents we had at our command…. I am sure I saved many lives by their use,
escaped septicaemia, and had rapid recoveries’’ (Baer 1931).

8. Current Status of MDT 1
• In January, 2004, the U.S. Food and Drug Administration (FDA) issued
510(k) clearance, thereby allowing the production and distribution of
"Medical Maggots" as a medical device.
• Similarly, in February, 2004, the British National Health Service (NHS)
permitted its doctors to prescribe MDT.
8

9. • Today, many therapists in the United States, Asia and Europe are using
MDT in woundcare management.
• In Africa, very few centres reported the use of this method while in
Nigeria, for the first time we announced the successful application of
MDT on various types of wounds.
9
Current Status of MDT 2

10. Wounds for MDT
Diabetic ulcers
Burns
Non-healing surgical wounds
Necrotising fasciitis
Osteomyelitis
Pressure sores
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11. Mechanism of MDT 1
• The mechanisms of action of medicinal maggots involve wound
debridement, disinfection, inhibition/eradication of biofilm and stimulation
of wound healing.
• Maggots feed on the dead tissues, bacteria, exudate and cellular debris
thus debriding and disinfecting the wound.
11

12. • Wound debridement decreases bacteria load, thus together with 20-
hydroxyecdysone stimulate the production of growth factors and
fibroblast required to promote wound healing.
12
Mechanism of MDT 2

13. • Furthermore, Maggot secrete proteolytic enzymes (trypsin, leucine
aminopeptidase, carboxypeptidase, tryptase, peptidase and lipase)
and alkaline such as calcium, urea, allantoin, and ammonium
bicarbonate which further inhibit bacteria growth by changing the
wound pH.
13
Mechanism of MDT 3

14. 14
Larval Morphology 1

15. 15
Larval Morphology 2

16. Some Studies on MDT 1
• Armstrong et al. (2005), compared the efficacy of MDT in 60 non
ambulatory patients with diabetic foot and 30 patients receiving
conventional therapy.
• MDT group had a significantly faster healing time compared to the
conventional therapy group. The mean healing time for MDT was 18.5
weeks while the conventional therapy was 22.4 weeks (P=0. 04).
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17. • The rate of amputations were significantly higher in the conventional
therapy group compared to the MDT group.
• Also the MDT group had more antibiotic free days compared to the
conventional therapy group (126.8 + 30.3 vs 81.9 +42.1 days,
P=.0001).
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Studies on MDT 2

18. • Dumville et al. (2009), in a randomized controlled trial conducted with
267 patients with at least one venous or mixed venous and arterial ulcer
with necrotic or slough tissue.
• In the MDT group, the median healing time was significantly lower than
the conventional therapy group and the MDT group had reduced
debridement time with a hazard ratio of 2.31.
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Studies on MDT 3

19. Patients’ Perception of MDT 1
• Agom et al. (2014), Steevoorde et al. (2005) and Kitching (2004)
reported a high acceptability of MDT in patients.
• McCaughan et al. (2013) reported that patients with leg ulcers after
MDT, remarked on the speedy visible improvements that ensued
during the course of therapy.
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20. • Spilsbury et al. (2008) reported a strong positive experience of odour
reduction and exudate among patients, while others commended the
high rate of wound healing in MDT as they would recommend it to
others.
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Patients’ Perception of MDT 2

21. 21
Experience of MDT from Aminu Kano Teaching
Hospital, Kano, Northwestern Nigeria

22. AKTH Experience 1
• Written informed consent was obtained from those administered with
MDT at Aminu Kano Teaching Hospital, Kano (AKTH).
• First instar larvae of L. sericata obtained from an indigenous company
were applied using the free-range method under aseptic conditions.
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23. 23
DMFU: Diabetes Mellitus Foot Ulcer
PTWI: Post Traumatic Wound Infection
NF: Necrotising Fasciitis
53.40%
30%
10%
6.60%
Diagnosis
DMFU III-IV
NF
PTWI
Others
Figure 1. Diagnosis of the Various Wounds Administered with Maggot Therapy at AKTH, 2020

24. 24
Table 3. Maggot debridement and clinical profile of the wounds (n=30)
Variable Frequency (%)
Days on admission before MDT
Median 8
Minimum 2
Maximum 35
Cycles of MDT
1 13(43.3)
2 15(50)
3 2(6.7)
Duration of MDT (days)
Median 4
Minimum 1
Maximum 7
Surface area (cm2
)
Median 56
Minimum 18
Maximum 288

25. 25
Table 4. Maggot debridement and clinical profile of the wounds (n=30)
Variable Frequency (%)
Bed-side surgical debridement
No 22(73)
Yes 8(27)
Pre MDT M/C/S
P. aeruginosa 5(16.7)
S. aureus 17(56.7)
S. aureus/S. pyogenes 1(3.3)
S. aureus/P. aeruginosa 2(6.7)
S. pyogenes 5(16.6)
Post MDT M/C/S
*Growth 4(13.3)
*No growth 26(86.7)

26. A paired sample t-test showing statistically significant difference between the pre and
post MDT slough
Paired sample t-test Statistics
N Mean Std. Deviation
Std. Error
Mean
Pre
MDT
Slough
30 1.583 .4956 0.0506
Post
MDT
Slough
30 1.469 .5016 0.0512
Paired sample t-test
Test Value = 0
t df P-value
Mean
Difference
95% Confidence
Interval of the
Difference
Lower Upper
Pre MDT
Slough
31.303 29 0.000 1.5833 1.483 1.684
Post MDT
Slough
28.687 29 0.000 1.4688 1.367 1.570
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27. 27
Fig 2. Cage dressing of maggot debridement therapy. (A) Cage without the maggots (B)
Cage with maggots and filter. (C) Crep bandage over the roof.
A B C

28. 28
Fig 3. A 58 year-old diabetic patient with fore foot gangrene and Necrotizing Fasciitis of the foot.
(A) Before maggot therapy. (B) After two cycles (120hrs) of maggot therapy

29. 29
Fig 4. A 40 year-old diabetic patient with osteomyelitis of the left leg. (A) Before maggot therapy,
after eight days of dressing (B) After one cycle (24hrs) of maggot therapy

30. 30
Fig 5. A 40 year-old diabetic patient presented to our facility with fore foot gangrene. (A) Before maggot
therapy. (B) Under maggot therapy. (C) After three cycles (192hrs) of maggot therapy

31. 31
Fig 7. A 58 year-old diabetic patient with fore foot gangrene. (A) Before maggot therapy. (B)
After two cycles (120hrs) of maggot therapy

32. 32
Fig 8. A 65 year-old patient presented to our facility with Necrotizing Fasciitis of the foot. (A) Before maggot
therapy. (B) After two cycles (120hrs) of maggot therapy (C) After skin graft (D) Healed completely
A B C/D

33. 33
Fig 9. A 23 year-old patient presented with Necrotizing Fasciitis of the foot. (A) Before maggot therapy. (B) After two
cycles (120hrs) of maggot therapy. (C) After skin graft.

34. 34
Fig 10. A 19 year-old patient presented with post-traumatic wound infection (PTWI). (A) After
surgical debridement before maggot therapy. (B) After one cycle (24hrs) of maggot therapy.

35. 35
Fig 11. A 58 year-old patient presented with DMFU complicated gas Gangrene. (A) Before maggot therapy. (B) X-ray
showing gas under the soft tissue skin graft (C) After two cycles (120hrs) of maggot therapy (D) Healing after MDT

36. 36
Fig 11. A 35 year-old patient with surgical site infection post appendectomy. (A) Before maggot therapy. (B)
After one cycle (24hrs) of maggot

37. 37
Fig 12. A 65 year-old patient presented with DMFU. (A) Before maggot therapy. (B) Under maggot therapy. (C)
After two cycles (120hrs) of maggot

38. 38
Fig 3. A 65 year-old man living with diabetes mellitus (A) Before maggot therapy (B) Under maggot therapy (C) After
three cycles (144hrs) of maggot therapy
A B C

39. A B C
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40. 40
A B C
Fig 3. A 65 year-old diabetic patient presented to our facility with pyomyositis at the back. (A)
Before maggot therapy. (B) Under maggot therapy. (C) After two cycles (96hrs) of maggot therapy

41. Conclusion 1
• Maggot debridement therapy was effective in the debridement and
significant disinfection of wounds involving different body parts, thus
enhancing wounds` healing with a good prognosis.
• Hence, the application of MDT is recommended for such wounds.
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42. Conclusion 2
• MDT is a simple and cost-effective treatment method for chronic
wounds in developing countries
• Minimal institutions are presently using this method in West Africa.
• Further clinical trial studies are needed where more parameters on
MDT can be accessed.
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43. Some Selected References
• Amstrong, D.C., Lavery L.A., Vazquez, J.R et al., (2002) How and why to surgically debride neuropathic diabetic foot wounds. J Am
Podiatr Med Assoc 92 (7), pp.398-404.
• Baer, W. S. (1931). The treatment of chronic osteomyelitis with the maggot (larva of the blow fly). J Bone Joint Surgery 13: 438-475.
• Cazander, G; Van Veen, K.E.B; Bernards, A.T. & Jukema, G.N. (2009) Do maggots have an influence on bacterial growth? A study on
the susceptibility of strains of six different bacteria species to maggots of Lucilia sericata and their excretions/secretions. Journal of
tissue viability 18, pp.80-87.
• Dumville, J.C., Worthy, G., Bland, M.J., Cullum, N., Dowson, C., Iglesias, C., Mitchell, J.L., Nelson, E.A., Soares, M.O. & Torgerson, D.J.
(2009) Larval therapy for leg ulcers (VenUS II): randomised controlled trial. British Medical Journal 338, pp.1047-1057.
• Hawker, S., Payne, S., Kerr, C., Hardey, M. and Powell, J. (2002) Appraising the evidence. Reviewing disparate data systematically.
Qualitative Health Research. 12(9), pp.1284-1299.
• Jarczyk, G., Jackowski, M., Szpila, K., Boszek, G., Kapelaty, S., Skwarek, E. & Michalak, M. (2008) Biosurgical treatment results in
patients with chronic crural and foot ulcerations. Polski Przeglad Chirurgiczny 80(4), pp.190-201.
• Jukema, G. N., Menon, A. G.w, Bernards, A. T., Steenvoorde, P., Taheri, R. A. & Van Dissel, J. T. (2002). Amputation-sparing
treatment by nature: ‘surgical’ maggots revisited. Clin Infect Dis 35: 1566-1571.
• Kirshen, C., Woo, K., Ayello, E. A. & Sibbald, R. G. (2006). Debridement: a vital component of wound bed preparation. Adv Skin
Wound Care 19: 506-517.
• Maggot debridement therapy: A primer. Journal of the American Podiatric Medical Association, 92(7), 398-401.
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44. Thank You
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