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Julie Jones, written during final year of B.Sc (Hons) Adult Nursing, Julie Green, Lecturer in Nursing, Keele University, Alison
Kate Lillie, PhD Lecturer in Nursing, Keele University
Email: juliejonesxxxx@yahoo.co.uk
Abstract
KEY WORDS
w Larval therapy w Maggot therapy w Chronic wounds w Leg ulcers w
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then transform into an acute wound; subsequently beginning the healing process a lot quicker. Over time, this will
reduce overall costs to the NHS; which is a constant goal
(Courtenay et al 2000; Mumcuoglu, 2001; Sherman, 2003).
Maggot therapy is not a new discovery; it has been
known to be conducive to effective wound management
for many years; albeit initially accidental infestations (Jones
and Andrews, 1998); with subsequent military use dating back to Napoleonic times. Today, this treatment has
a growing popularity and specially constructed laboratories owned by companies such as BioMonde (formerly
ZooBiotic) Ltd. based in Brigend, South Wales, who
regularly supply sterile larvae to NHS trusts all over the
UK (BioMonde, 2010).
Maggot applications are provided in two different
preparations. The BioFOAM dressing is a woven net bag,
containing a number of maggots each a few millimetres
long. These are available in varying sizes, depending upon
demands of the wound. BioFOAM dressings contain
products that support and stimulate maggot activity, while
containing exudates (Figure 1). These are then held in place
with a secondary dressing.
The maggots are also available free-range, whereupon
they are supplied in a clear container and placed directly
onto to wound (Figure 2), which is then covered with
a fine mesh or stocking (depending upon the extent of
the wound) with some adhesive around the outer edge
to secure the dressing. The wound should be measured
and a larvae calculator used to order the correct amount
(BioMonde, 2010; Knowles et al, 2002).
Despite maggot therapy gaining in popularity, and being
deemed a highly efficient method of chronic wound debridement, it still remains cosmetically unappealing to the
majority of patients and nursing staff (Thomas and Jones,
2000). While maggot therapy is accepted and adopted as a
one of the best debridement techniques for future management of chronic wounds (Sherman, 2005), many areas
for improvement surrounding maggot therapy were identified via analysis of literature on the subject.
Literature search
Search strategy
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Search results
Table 2 lists the numbers of results gained from the varying internet sources. The total number of articles accessed
using the search strategy prior to applying the inclusion/
exclusion criteria was 106. However, once this was applied,
the number was reduced to 7 articles that were appropriate
for reviewing.
A well-established critiquing tool; Critical Appraisal
Skills Programme (CASP) has then been used to critique
the research collated, via a framework devised of questions
that are asked and serve to test/ascertain the robustness of
the studies and establish whether the findings from the
studies were appropriate and thus applicable to clinical
practice for future impact (Public Health Resource Unit
(PHRU), 2006).
Four key themes were identified and analysed from this
search, including infection control, promotion of healing,
cost effectiveness and the yuk factor.
Infection control
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Table 2.
Inclusion criteria
Exclusion criteria
Database
Research available in
English
Number of articles
11
Research prior to
1995
CINAHL
45
Paediatric patients
EMBASE
15
Chronic wounds
Acute wounds
MEDLINE
Secondary care
focus
12
Google Scholar
Published research
Unpublished
research
Pubmed
15
Promotion of healing
A chronic wound is one which is non-healing and often
incorporates bacteria-laden slough, which has to be debrided if the wound is to heal (National Institute for Health
and Clinical Excellence (NICE), 2001; Cutting et al 2002;
Ayello et al 2004). Wound healing is a complex biological
process, and it is imperative that all clinicians involved in
wound care, understand the process which prevents, minimizes and eliminates factors which adversely effect wound
healing (Cutting et al, 2002).
Wound healing includes four stages; haemostasis, inflammation, proliferation and maturation, occurring independently and simultaneously (University Hospital of North
Staffordshire (UHNS) 2001; Wound Care Formulary, 2001;
Shipperely and Martin, 2002; Timmons, 2006). Maggot
therapy is considered to be instrumental in the breaking
down of necrotic tissue in chronic wounds, and encourages
healthy, granulating tissue in wound beds (Sherman, 2003;
Acton, 2007; BioMonde, 2010).
To investigate this theory, a key study by Dumville et al
(2009), called the VenUS II Trial, was carried out, which
had two main objectives:
w To assess the clinical effectiveness of maggot therapy in
comparison to hydrogel, a standard debridement treatment
w To assess the clinical effectiveness of loose maggots in
comparison to bagged maggots
This pragmatic, three-armed randomized controlled
trial (RCT) compared loose maggots, bagged maggots
and hydrogel, and involved 267 patients with venous or
mixed aetiology ulcer wounds, each with a 25% sloughy
area/necrotic tissue. The study concluded that overall maggot therapy proved to be no more effective in reducing
bacterial load or improve healing rates within sloughy or
necrotic ulcers when compared with hydrogel, but it did
appear to improve debridement times. However, ulcer pain
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Cost-effectiveness
Approximately 200 000 people each year in the United
Kingdom suffer from chronic wounds at any one time,
costing the NHS in excess of 2.3bn3.1bn per year to
care for them (Posnett and Franks, 2008). As a result, a
number of studies to assess the cost effectiveness of maggot therapy in comparison to conventional treatments have
been undertaken (Thomas, Banks, and Bale, 1997).
One study in particular conducted by Wayman et al
(2000), involved 12 patients with venous ulcers that were
sloughy. All the patients were allocated to either the maggot
therapy group or alternatively the hydrogel therapy group.
The participants were observed up until debridement had
occurred, or up to a maximum of a month. Results showed
that some patients had achieved debridement in just one
application of maggot therapy, while in contrast; some of
those receiving the hydrogel treatment were still requiring
dressings one month later.
The cost implication proved greater with the hydrogel
treatment, which was found to be 136.23, compared to
78.64 for the maggot therapy patients. However, the true
cost can only be measured once the number and frequency
of nursing visits in addition to the cost of treatments has
been established. It was also recognized that despite the
fact that the randomization supported validity/reliability,
the study was not blinded and therefore open to bias,
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findings, which was centred upon 41 patients with nonhealing wounds in hospital in the Netherlands. Following
treatment, out of the 37 that returned questionnaires, none
expressed a negative response towards maggot therapy, and
said furthermore, that they would recommend it to others.
As there exists a similarly up-to-date provision of medical
care, this can be judged as generalizable globally.
These results also echoed an earlier study by Courtenay
(1999), extending to 23 hospitals throughout the UK.
In this study a qualitative approach was adopted, with
the collection of documentary evidence and data from
semi-structured interviews. After liaising with nurses and
patients at each one, Courtenay (1999) concluded that
those with little or no prior experience/knowledge of
maggot therapy were the more reluctant to contemplate
initiating the treatment, and considered it a last option,
while those with prior experience/knowledge embraced
the notion of implementing maggot therapy into their
patients wound treatment regime.
From the literature reviewed in this section, support,
guidance and training in maggot therapy was flagged up as
instrumental in eliminating the so called yuk factor, the
provision of up-to-date, honest information regarding the
processes involved and perceived outcomes of the therapy,
encouraging more practitioners/patients to be accepting of
maggot therapy. In such instances nurses can greatly influence patient choice with good quality information and
honest communication (Courtenay et al, 2000; Thomas,
2001; Jukema et al, 2002; Sherman, 2003).
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key points
w
The conservative treatment of chronic wounds currently costs the NHS in
the region of 200 million per year.
w
Maggot therapy has been shown to dramatically reduce healing time and
overall costs associated with chronic wound management.
w
Further research is suggested to support and encourage greater use of
maggot therapy within the clinical environment.
w
Improved training and education for practitioners and patients is required
to challenge barriers associated with maggot therapy, i.e. the yuk factor.
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