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Contraindications to Maggot Debridement Therapy
José Contreras-Ruiz, MD

Not a single method of debridement achieves improvement in the absence of proper nutrition, tissue oxygenation and elimination of causative factors, so the basic principles of debridement continue to apply.

Contraindications

Absolute
All patients should consent and be part of the treatment so it is contraindicated in the absence of a well- informed patient or their caregiver.1-4 Using non-sterile maggots can cause severe deadly infections so sterile maggots should always be used.2,5-11 Pyoderma gangrenosum is an inflammatory ulcerative condition of the skin where debridement in the active phase can cause wound enlargement (pathergy).12-14 MDT is contraindicated therefore in active pyoderma gangrenosum in the absence of proper treatment.

Fatal consequences of MDT can result from application on wounds likely to communicate to the central nervous system, a large blood vessel, body cavities or vital organs.15

MDT is contraindicated in necrotizing or rapidly advancing infections (necrotizing fasciitis, gaseous gangrene) and sepsis since regular surgery is faster and life saving.1,16,17

Relative
An ischemic wound will rarely heal despite debridement if proper vascular supply is not present. Therefore wounds without the proper circulation should not be debrided unless they show signs of overt infection (fluctuant, edematous, erythematous, pus).18 These wounds should be monitored. Under certain circumstances and with proper explanation to the patient of the aim, MDT can be used to decrease the bulk of necrotic tissue to decrease odour of exudates. Sometimes even in these circumstances wounds have healed.1,19 In some of these cases prophylactic antibiotics have been recommended as in surgical debridement.20,21

Surgery is more efficient to debride bone; however MDT can be used to debride the tissue around the bone and promote granulation in the absence of osteomyelitis.1,22,23

In deep fistulas or undermining MDT application and removal becomes difficult and sometimes incomplete. No complications, however, have been reported with incomplete maggot removal. We have used them prior to using the VAC since those maggots that could be left in are killed by hypoxia and biodegraded.

If a patient can’t stay off the maggots the therapy is useless. This is particularly troublesome between the toes, on the heel and in some ambulatory patients.

Theoretical
None of the following have been reported; however given the nature of the therapy, caution should be exercised in the following scenarios. Some maggot producers utilize egg albumin or soy protein to breed them so a history of allergies to these substances must be taken. Other potential allergies could be to the maggot secretions or the dressings used to encage them.24

Immunosuppressed patients could be more prone to invasion or to a severe infection. Another potential complication could be ammonia toxicity that could induce encephalopathy in patients with liver failure.16

References

  1. Sherman RA. Maggot therapy for foot and leg wounds. Lower Extremity Wounds. 2002;1:135-142.
  2. Mumcuoglu KY. Clinical applications for maggots in wound care. Am J Clin Dermatol. 2001;2:219-227.
  3. Jones M, Thomas S. Larval therapy. Nurs Stand. 2000;14:47-51.
  4. Sherman RA, Sherman J, Gilead L, Lipo M, Mumcuoglu KY. Maggot debridement therapy in outpatients. Arch Phys Med Rehabil. 2001;82:1226-1229.
  5. Baer W. The treatment of chronic osteomyelitis with the maggot (larva of the blow fly). J Bone Joint Surg. 1931;13:438-475.
  6. Weil GC, Simon RJ, Sweadner WR. A biological, bacteriological and clinical study of larval or maggot therapy in the treatment of acute and chronic pyogenic infections. Am J Surg. 1933;19:36-48.
  7. Nuesch R, Rahm G, Rudin W et al. Clustering of bloodstream infections during maggot debridement therapy using contaminated larvae of Protophormia terraenovae. Infection. 2002;30:306-309.
  8. Wollina U, Karte K, Herold C, Looks A. Biosurgery in wound healing--the renaissance of maggot therapy. J Eur Acad Dermatol Venereol. 2000;14:285-289.
  9. Sherman RA. Maggot therapy - The last five years. Eur Tissue Repair Soc. 2000;7:97-98.
  10. Bunkis J, Gherini S, Walton RL. Maggot therapy revisited. West J Med. 1985;142:554-556.
  11. Rufli, T., Steffen, I, and Nuesch, R. Sepsis as a complication of maggot therapy. 5th International Conference on Biotherapy . 2004. Wurzburg, Germany. Ref Type: Conference Proceeding
  12. Kelly J. Pyoderma gangraenosum: exploring the treatment options. J Wound Care. 2001;10:125-128.
  13. Budak E, Er H, Cagdas A, Karaman Y. Pyoderma gangrenosum at the incision site following gynecologic surgery. Eur J Obstet Gynecol Reprod Biol. 2004;116:117-119.
  14. Waterworth AS, Horgan K. Pyoderma gangrenosum--an unusual differential diagnosis for acute infection. Breast. 2004;13:250-253.
  15. Courtenay M, Church JC, Ryan TJ. Larva therapy in wound management. J R Soc Med. 2000;93:72-74.
  16. Sherman RA, Hall MJ, Thomas S. Medicinal maggots: an ancient remedy for some contemporary afflictions. Annu Rev Entomol. 2000;45:55-81.
  17. Sherman RA, Shimoda KJ. Presurgical maggot debridement of soft tissue wounds is associated with decreased rates of postoperative infection. Clin Infect Dis. 2004;39:1067-1070.
  18. Bergstrom, N. Clinical practice guideline number 15: treatment of pressure ulcers. Bennett, M. A. and Carlson CE. AHCPR Publication 95-0652. 1994. Rockville, MD, Agency for healthcare policy and research (AHCPR). Ref Type: Generic
  19. Pressure ulcer treatment. Agency for Health Care Policy and Research. Clin Pract Guide: Quick Ref Guide Clin. 1994;1-25.
  20. Courtenay M, Church JC, Ryan TJ. Larva therapy in wound management. J R Soc Med. 2000;93:72-74.
  21. Thomas S, Jones M, Shutler S, Jones S. Using larvae in modern wound management. J Wound Care. 1996;5:60-69.
  22. Sherman RA, Shimoda KJ. Presurgical maggot debridement of soft tissue wounds is associated with decreased rates of postoperative infection. Clin Infect Dis. 2004;39:1067-1070.
  23. Sherman RA. Maggot debridement in modern medicine. Infect Med. 1998;15:651-656.
  24. Drisdelle R. Maggot debridement therapy: a living cure. Nursing. 2003;33:17.

 
   

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Last modified: April 29, 2005