Healthcare providers’ guide to maggot therapy in conflict-affected communities and other compromised healthcare settings

This is a guide for doctors, nurses, and others who care for patients with wounds and who want to learn how maggot therapy is administered.

Treatment Manual

Clear messaging, education, and the sensitisation of healthcare professionals is critical for the mainstreaming of maggot therapy across healthcare systems and care organisations. This is why we have developed a Treatment Manual consisting of eleven fact sheets. They are written in non-technical language, are richly illustrated and include a general introduction to maggot therapy (Treatment Manual T1) and a highly accessible information sheet for patients and their families (Treatment Manual T2). The remainder of the Treatment Manual offers easily accessible information about what types of wounds can be treated with maggot therapy, when maggot therapy should be avoided, and when it should be used with caution. The Treatment Manual also explains how the right maggot therapy dressing is selected and how it is applied to a variety of wound types and wound locations. The information is presented in 11 separate fact sheets, in English, French, and Arabic.

T1 Wound care with maggot therapy
T2 Maggot therapy – Information for patients and their families
T3 Wounds that can be treated with maggot therapy
T4 When maggot therapy should be avoided or used with great caution
T5 Things that may harm medicinal maggots or influence their performance
T6 Wound types and their location on the body
T6 Maggot therapy dressing decision support tool
T7 Two-dimensional dressing to confine medicinal maggots during maggot therapy
T8 Bagged application of maggots for extra secure containment of medicinal maggots
T9 Tubular glove and sock confinement dressings for the treatment of wounds on hands and feet
T10 Tubular confinement dressing for circumferential application of medicinal maggots
T11 Materials

Treatment videos

We have produced two instructional videos that explain step-by-step the treatment process for free-range maggot therapy in both the high-resource healthcare setting and in low-resource healthcare settings.

There are two main dressing categories for maggot therapy, and they vary in the way maggots are kept on the wound and prevented from escaping. In the first method, maggots are placed directly onto the wound and kept in place with a confinement dressing. It is simply a cage made of a tightly woven mesh fabric that is taped to the skin surrounding the wound. Because the maggots are free to access the necrotic tissue, this method is also known as free-range maggot therapy.

The other option is to put maggots into a small pouch or bag made of tightly woven polyester or nylon fabric. The sealed pouch with the maggots is placed onto the wound. This is possible because maggots excrete digestive enzymes into the wound which liquefy the dead tissue. It is this liquid and not solid tissue that they consume. However, bagged application of maggots is less effective than free-range maggot therapy and it takes longer, too. Besides, it can be technically challenging to produce securely sealed mesh bags, especially in low-resource healthcare settings. Free range dressings are constructed at the bedside and can be modified to suit wounds and the resources that are available to healthcare providers. For these reasons we have described free-range application of medicinal maggots in these instructional videos.

Each of the step-by-step guides to free-range maggot therapy is provided in three languages with English, French, and Arabic interpretation text. Please note the videos are not narrated. All information is conveyed visually.

An infected fasciotomy wound on the lower leg has been chosen to illustrate the procedures. With slight modifications, free-range maggot therapy can be applied to most parts of the body. Please refer to our Dressing Decision Support Tool to identify the best dressing modality for your patients’ maggot therapy needs.

Note: Free-range maggot therapy is contraindicated where cage dressings cannot be constructed securely or there is a danger maggots could enter body cavities such as the eyes, the ear canal, the mouth, the nose, the vagina, male urethra, the anus, or any wound that provides access to internal organs. In such instances, bagged maggots should be used for treatment.

A more detailed discussion of when maggot therapy can and cannot be used and how it might interact with other patient characteristics is provided in

Treatment Manual T3: Wounds that can be treated with maggot therapy
Treatment Manual T4: When maggot therapy should be avoided or used with great caution
Treatment Manual T5: Things that may harm medicinal maggots or influence their performance

Step-by-step guide to maggot therapy in
high-resource healthcare settings – English

Step-by-step guide to maggot therapy in
low-resource healthcare settings – English

Step-by-step guide to maggot therapy in
high-resource healthcare settings – French

Step-by-step guide to maggot therapy in
low-resource healthcare settings – French

Step-by-step guide to maggot therapy in
high-resource healthcare settings – Arabic

Step-by-step guide to maggot therapy in
low-resource healthcare settings – Arabic

References

The production of the Treatment Manual and the two Treatment Videos has been guided by clinical evidence and guidelines for maggot therapy. We have consulted, synthesised and adopted the findings and recommendations presented in these and other publications:

  • Sherman, R. A. and M. R. Hetzler (2017). “Maggot Therapy for Wound Care in Austere Environments.” J Spec Oper Med 17(2): 154-162.
  • Chadwick, P., et al. (2015). “Appropriate use of larval debridement therapy in diabetic foot management: consensus recommendations.” Diabetic Foot Journal 18(1): 37-42.
  • Wound Healing and Management Node Group (2014). “Recommended practice: wound debridement – larval therapy.” Wound Practice and Research 22(1): 48-49.
  • The All Wales Guidance for the Use of Larval Debridement Therapy (LDT). (2013) https://www.biologiq.nl/UserFiles/The%20All%20Wales%20Guidance%20for%20the%20Use%20of%20Larval%20Debridement%20Therapy%20(1).pdf
  • Mexican Association for Wound Care and Healing (2010). “Clinical Practice Guidelines for the Treatment of Acute and Chronic Wounds with Maggot Debridement Therapy.”
  • British Columbia Provincial Nursing Skin and Wound Committee (2014). “Guideline: Maggot Debridement Therapy (MDT) in Adults & Children.” https://www.clwk.ca/buddydrive/file/guideline-maggot-debridement-therapy/.
  • Acton, C. (2007). “A know-how guide to using larval therapy for wound debridement.” Wound Essentials 2: 156-159.

Treatment Manual feedback and MedMagLabs responses

You write:….In such places, nurses and even untrained lay carers can treat patients with maggot therapy… […] Though the application of maggots (and perhaps also their removal from the wound) could be done by more or less everybody, I think that it should be very clearly said that everything should be done under the supervision and responsibility of a physician. He/she should more or less know how to apply, how many maggots to use, how long to leave on the wound, when to remove, what to do during those 2-3 days of a treatment cycle, when to debride the large necrotic parts of wound, and what to do when any complication appears (e.g., pain). I would suggest that you use the words “apply maggots” than “treat patients”

MedMagLabs response

In an ideal world there would be trained doctors, surgeons, and nurses familiar with maggot therapy. However, this is the real world and if communities want to try maggot therapy, they must grow their own medicinal maggots, and without trained doctors, lay carers have to treat patients with chronic or infected wounds. The sad reality is that in many parts of the world there is a terrible shortage of doctors and nurses. Where there are no doctors and nurses it is up to family carers and community nurses to look after the ill. Our research and development project sought to bring hope to exactly these isolated and abandoned populations. We needed to develop instructional resources that make it easy for lay persons to produce safe medicinal maggots and treat patients. We believe that our instructions, if studied carefully, provide the necessary information in a format that is accessible to lay persons and community nurses.

You write:…Patients must not immerse dressings. Maggots will drown… We also ask the patients and the health care providers not to wet the dressing in order not to stop the drainage of the liquids produced by the wound and the maggots, however biologically I can imagine that it will be very difficult to drown maggots in water. I did an experiment with body lice and they survived at least 15 hrs. under water!! Maggots should do it even better!.

MedMagLabs response

You are correct in suspecting that maggots can survive and even thrive in liquids for some time and even longer when they can breathe via their breathing organs (spiracles) at the end of their body from time to time. However, prolonged inundation in liquids leads to a lack of oxygen. Insects are quite tolerant of temporary oxygen shortage and researchers exploit this when they anaesthetize flies with CO2. After a while, when the flies are returned to oxygen-rich air, they wake up and go about their business as usual. The same is true for maggots. When submersed for a while in water they slow down and may even become immobile but when removed from the water they regain their former activity level. Therefore, it stands to reason that, even though maggots can survive temporary submersion in water, their reduced activity will most likely impact treatment and efficacy.

Again, it is important that our instructions are easily understood by people with no prior experience in entomology. The idea that drowning is detrimental to a maggot can be easily understood without the need to discuss the respiratory physiology of the animal.

You write: …Apply medicinal maggots at a dose of 5-10 per cm2 to the wound… Although I see this number in several publications, we know that perhaps this is true for an superficial wound but these number of maggots will do little in a deep wound with a lot of sloughy and necrotic tissue.

MedMagLabs response

This makes sense. A wound that is deep and uneven in its three-dimensional shape has a greater surface area and therefore requires more maggots for complete debridement. Even in such cases, the recommended 5-10 maggots per cm2 are likely to deliver some therapeutic benefit with carers and patients seeing progress. Elsewhere in the guidance material, we recommend repeat treatment if too few maggots have been applied for some reason.

You write:…Remove bagged maggots after 3-4 days… Perhaps it should be added that the bagged maggots should be placed each time in the areas which need debridement, as they do not have the possibility to move around as the free-range ones. It is possible that those biobags are displaced during the 3-4 days of treatment and should be brought to the “right” places.

MedMagLabs response

This is a helpful suggestion and we will provide this advice in our next edition of the Treatment Manual. In the meantime, we trust that carers notice where the biobag has achieved debridement and depend on their common sense to place the next round of biobags (if a repeat is required) directly onto areas of the wound that require further debridement.

You write: …Remove maggots after 2-3 days…As you know, there are many disadvantages in leaving maggots for long periods of time on the wound. It is possible that the maggots debrided the area after e.g., one day and [leaving] them on the wound will only cause additional pain and maceration of the wound. It is also possible that the adhesive bands which are used for the cage-like dressing become loose and maggots start escaping. Though it is more time consuming we are using whenever possible a 24-hour maggot cycle.

MedMagLabs response

We were careful to provide treatment advice that is based on published nursing guidelines and the literature. Your advice to reduce the time for each treatment cycle to one day has some merit. A more nuanced recommendation around treatment length may be required in the next version of the manual. In the meantime, we regard the potential risk as minimal in low-resource and austere healthcare settings. There is always the risk of escaping maggots from failing free-range dressings and carers will in time learn to improve and monitor the dressing to avoid escapes.

Though the Zink crème is a good solution to protect the skin around the wound, we are placing the adhesive bands in a way that only the wound is exposed to the maggots

MedMagLabs response

This is a good suggestion. We have based our treatment advice on published best-practice treatment guidelines for free-range treatment, which include protection of exposed skin around the wound with Zink crème. Personal communication with some practitioners suggested that skin protection may even be optional for the brief period of maggot therapy. A slight irritation of the surrounding skin from larval activity may be acceptable. Our treatment video demonstrations were also limited by the fake wound makeup (maulage) which prevented us from sticking the hydrocolloid barrier too close to the wound edge.

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