Pain related to maggot debridement therapy

Abstract

To summarise our experience with maggot debridement therapy (MDT) in relation to pain observed in patients treated in 16 departments and units of the Hadassah Hospital in Jerusalem, Israel.
A secondary analysis of data from 435 patients. Maggots were either placed directly on the wound using a cage-like dressing (DA), or they were applied to the wound encased in a previously prepared hermetic tea-bag like pouch (TBA). During each treatment, patients were asked whether they felt any difference in the level of pain before and during MDT treatment.
Overall, 165 patients (38%) reported increased pain during MDT. Seventeen patients (41%), who were treated with the TBA technique, and 148 patients (38%), who were treated with the DA technique, reported increased pain and were treated with analgesics before or during MDT. In five patients, the treatment had to be discontinued due to uncontrolled pain during MDT. Pain control measures were undertaken in patients who were already in intense pain prior to the initiation of MDT and in those patients who reported intense pain during DA treatment. The measures included shorter periods of application of maggots, use of the TBA rather than DA technique, and applying relatively small maggots as well as a smaller number of maggots during an MDT session. In patients who continued reporting intense pain, systemic analgesic medications and peripheral nerve blocks were used.
Since a full debridement requires an average of 2-3 maggot cycles, which last 3-5 days, and since a large percentage of patients treated with MDT complain of pain that may last throughout the therapy period, it is deemed worthwhile and even essential to titrate analgesics as needed and be prepared to treat patients even with potent analgesics, such as opioids. In cases when pain is intense and uncontrolled with systemic medications, peripheral nerve blocks should be considered.
There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Full text

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JOURNAL OF WOUND CARE VOL 21, NO 8, AUGUST 2012400
Pain related to maggot
debridement therapy
l Objective: To summarise our experience with maggot debridement therapy (MDT) in relation to pain
observed in patients treated in 16departments and units of the Hadassah Hospital in Jerusalem, Israel.
lMethod: A secondary analysis of data from 435patients. Maggots were either placed directly on the
wound using a cage-like dressing (DA), or they were applied to the wound encased in a previously
prepared hermetic tea-bag like pouch (TBA). During each treatment, patients were asked whether they
felt any difference in the level of pain before and during MDT treatment.
lResults: Overall, 165patients (38%) reported increased pain during MDT. Seventeen patients (41%),
who were treated with the TBA technique, and 148patients (38%), who were treated with the DA
technique, reported increased pain and were treated with analgesics before or during MDT. In ve patients,
the treatment had to be discontinued due to uncontrolled pain during MDT. Pain control measures were
undertaken in patients who were already in intense pain prior to the initiation of MDT and in those
patients who reported intense pain during DA treatment. The measures included shorter periods of
application of maggots, use of the TBA rather than DA technique, and applying relatively small maggots as
well as a smaller number of maggots during an MDT session. In patients who continued reporting intense
pain, systemic analgesic medications and peripheral nerve blocks were used.
lConclusion: Since a full debridement requires an average of 2–3maggot cycles, which last 3–5days,
and since a large percentage of patients treated with MDT complain of pain that may last throughout the
therapy period, it is deemed worthwhile and even essential to titrate analgesics as needed and be
prepared to treat patients even with potent analgesics, such as opioids. In cases when pain is intense and
uncontrolled with systemic medications, peripheral nerve blocks should be considered.
lDeclaration of interest: There were no external sources of funding for this study. The authors have
no conicts of interest to declare.
Lucilia sericata; maggot debridement therapy; side-effects; pain; peripheral nerve blocks
M
aggot debridement therapy (MDT),
also called larva therapy, is the
intentional treatment of suppura-
tive skin infections with the larvae
of calliphorid ies. First introduced
by Baer in 1931,1 this method was used extensively
in the 1930s and early 1940s in over 300hospitals
in the USA alone.2–4 However, MDT was abandoned
with the introduction of antibiotics and the use of
aggressive surgical debridement.
Between 1950 and 1980, MDT was used only
occasionally as salvage therapy for skin and soft
tissue wounds that did not respond to surgery or
antibiotics.5–8 In 1989, MDT was re-introduced for
the treatment of intractable wounds in the USA,9–11
and since the mid 1990s it has also been used in
Israel,12–14 the United Kingdom,15,16 Sweden,17 and
Germany.18 MDT practice is currently estimated to
involve over 3000doctors, clinics and hospitals, in
over 24countries. In 2008, approximately 50 000
treatments were administered to more than 10 000
patients.19 Today, 20 years after its reintroduction,
we estimate that more than 80 000 patients have
been treated by MDT.
MDT is used as an adjunct therapy in necrotic and
infected wounds when antibiotic treatment, surgi-
cal debridement, high tech advanced dressings,
drainage and other conventional methods do not
halt or reverse the progressive tissue destruction.
MDT has been shown to achieve debridement of
necrotic wounds signicantly faster than most con-
ventional treatment methods.18,20,21
MDT usually employs sterile maggots of the green
bottle y, Lucilia sericata, and is used for any kind of
purulent, sloughy wound on the skin, independent of
the underlying disease or the location on the body,
for ambulatory as well as for hospitalised patients. In
80–95% of the cases, a complete or signicant debri-
dement of the wound is achieved by MDT.21
Although many patients do not report major dis-
comfort during MDT, maggots can induce, or inten-
sify, wound pain and at the surrounding tissues, espe-
cially in patients with supercial wounds and those
who were in pain prior to the initiation of MDT. The
pain related to MDT at times may be severe enough
to necessitate discontinuation of treatment.21
In a separate study, the authors’ experience with
MDT, in the setting of a modern hospital in Israel, and
K.Y. Mumcuoglu,1 PhD;
E. Davidson,2 MD;
A. Avidan,2 MD;
L. Gilead,3 MD, PhD;
1 Department of
Microbiology and
Molecular Genetics, The
Kuvin Center for the
Study of Infectious and
Tropical Diseases,
Hadassah Medical School,
The Hebrew University,
Jerusalem, Israel;
2 Department of
Anesthesia and CCM,
Hadassah University
Hospital, Jerusalem, Israel;
3 Department of
Dermatology and
Venereology, Hadassah
University Hospital,
Jerusalem, Israel.
Email: kostam@
cc.huji.ac.il

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JOURNAL OF WOUND CARE VOL 21, NO 8, AUGUST 2012402
in the treatment of hospitalised and ambulatory
patients with intractable, chronic wounds was inves-
tigated.22 During the years 1996–2009, 723wounds of
435patients were treated by MDT in 16departments
and units of the Hadassah Hospital in Jerusalem. In
82.1% of the wounds complete debridement was
achieved, while in 16.8% of the wounds the debride-
ment was partial and in 1.1% ineffective.22
The aim of this report is a secondary analysis of
the data, to summarise our experience with MDT in
relation to pain observed in the above-mentioned
435patients.
Method
Maggots and their application
Sterile maggots of the green bottle y, Lucilia serica-
ta, were cultured according to previously described
methods.13 Maggots were either placed directly on
the wound using a cage-like dressing, which pre-
vents them from escaping but allows air to reach the
maggots and facilitates the drainage of liqueed
necrotic tissue through the top of the dressing
(direct application, DA), or the maggots were
applied to the wound encased in a previously pre-
pared hermetic tea-bag like pouch composed of two
0.5mm-thick layers of polyvinyl alcohol netting,
which were sealed together with a head-sealer (Mer-
cier Corp.) over a small cube of a spacer material
(tea-bag application [TBA] method). The maggots
are thus able to feed through the netting and their
secretions reach the wound bed in order to digest
the necrotic tissue extra-corporeally.
Patients
From 1996 to 2009, details of all MDT treatments
were collected and documented. For each patient a
standardised protocol was lled in and the number of
treatments, number of maggots applied, pain, treat-
ing physician and outcomes were all documented in
this protocol, for the entire treatment period.
In total, 723wounds of 435patients (180females
and 255 males) were treated with MDT in 16
departments and units of the Hadassah Hospital in
Jerusalem, Israel. Overall, 261patients were treated
during hospitalisation, while 174 were treated as
ambulatory patients. In 91% of the patients, the
wounds were located on the leg, but only 48%
had diabetic foot ulcers. The wound duration
ranged from 1 to 240months (mean=8.9months;
median=4months; Table1). In 91% of the cases the
DA and in 9.4% of the cases the TBA methods were
used. The number of treatments ranged from 1
to 48 (mean=3.0; median=2) and the duration of
the treatment varied from 1–81 days (mean=4.7
days; median=3 days). In 357 patients (82%)
complete debridement of the wound was achieved,
while in 73 patients (17%) the debridement was
partial and in ve (1.1%) it was ineffective.22
All treatments were conducted by one of the
authors (KYM), who is a parasitologist and biothera-
pist. Written informed consent was obtained from
all patients or their custodians, as well as from the
responsible physician. The treatments were carried
out in the form of an open study and approved by
the institutional review board.
Pain assessment
All patients treated with MDT in the study period
were assessed daily by our team. During the visit,
they were asked whether they felt any difference in
the level of pain before and during MDT treatment.
Specically, they were asked whether they felt that
MDT caused them increased pain, and whether pain
Table 1. Demographics and general
medical background of patients treated
with maggot debridement therapy
No. of patients 435
Sex
lMale 255 (58.6%)
lFemale 180 (41.4%)
Age (years) 66.3
lMedian 68 (19–100)
Place of treatment
lHospitalised 261 (60.0%)
lAmbulatory 174 (40.0%)
Department
lDermatology 243 (63.1%)
lVascular surgery 38 (9.6%)
lInternal medicine 37 (9.6%)
lOrthopaedics 31 (8.1%)
lOther 86 (9.6%)
No. of wounds 725
lMean no. per patient 1.6
lMedian no. per patient 1
Location of the wounds
lLegs 656 (90.5%)
lSacrum 58 (8.0%)
lHands 11 (1.5%)
Wound duration (months) 1–240
lMean 8.9
lMedian 4
Background disease
lDiabetes 209 (48.0%)
lVenous stasis 74 (17.0%)
lVascular stasis 48 (11.0%)
lOther 104 (24.0%)
Results given as n (%), unless otherwise specied

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JOURNAL OF WOUND CARE VOL 21, NO 8, AUGUST 2012404
was slightly, moderately or signicantly higher than
before the initiation of MDT. Patients were not
assessed specically for neuropathic pain, and no
records were taken of the different types of pain;
however, the severity of pain was recorded.
Results
Overall, 165patients (38%) reported increased pain
during MDT. Seventeen out of 41 patients (41%)
treated with the TBA technique, and 148 out of
394patients (38%) treated with the DA technique,
reported increased pain and were treated with anal-
gesics before or during MDT. Five patients request-
ed to discontinue the MDT treatment due to an
unbearable increase in pain, unrelieved with
systemic analgesic medication.
Preemptive pain control measures were taken for
patients with a previous history indicating a signi-
cant risk for pain that may interfere with MDT, such
as those reporting continuous consumption of anal-
gesic medication, sleep deprivation due to wound
pain, and patients who received recurrent MDT treat-
ments and were known to have suffered increased
discomfort and pain during the treatment.
Pain control measures were selected to be more
potent than the ones previously used by the patient,
or according to the degree of discomfort reported
by the patient. These included, in the milder cases,
oral paracetamol and dipyrone, and in moderate
cases potent opioids, such as slow and immediate
release oxycodone HCl, tramadol HCl or a fentanyl
patch. In severe cases, when extreme pain was pre-
dicted or already encountered by patients in past or
present treatment, a continuous peripheral nerve
block was introduced prior to treatment initiation
(depending on the anatomical region of the wound
a sciatic, femoral or brachial plexus block), and
continuous pain control was maintained through-
out the MDT course.
Nineteen continuous peripheral blocks (12female
and 7 male patients, aged 41–91 years [median
71years]) were inserted for periods of 2–8days. The
majority (n=17) were continuous sciatic blocks
inserted at the popliteal or gluteal region. Peripheral
nerve blocks were performed with the aid of a nerve
stimulator (Polystim II; Temena Group). Catheters
for administration of local anaesthetics (continuous
administration bupivacaine 0.1–0.2% 4–6ml/hour;
bolus injection bupivacaine 10–25ml 3–4 times dai-
ly) were inserted using an insulated needle (Con-
tiplex Tuohy; B. Braun).
Catheters were observed daily by the acute pain
service. If any signs of local infection were observed,
the catheters were removed. No complications, such
as nerve injury or severe or deep infection, were
observed in patients treated with continuous blocks.
These measures resulted in a considerable reduc-
tion in pain associated with MDT, as reported by the
patients during their daily assessments, and thus
enabling the patients to complete the full treatment
and benet from its signicant advantage over alter-
native methods, saving both time and suffering.23
Discussion
In the present study, 38% of the patients reported
increased pain during treatment with maggots. In
earlier studies,14,21 we reported that approximately
20–25% of patients with supercial, painful wounds
complained of increased pain during treatment with
maggots, and were treated with analgesics.
Similar results were published by Sherman et al.,24
who reported that, during MDT, the most common
patient complaint was the physical discomfort.
Although treatment-associated pain has been
reported in only 6% of nursing home patients
(n=113), pain was reported in 38.1% (n=21) of
ambulatory patients.
Wollina et al.25 used MDT to debride the wounds
of 30patients with chronic leg ulcers of mixed ori-
gin. Twelve patients (40%) reported temporary pain,
but only two needed analgesic treatment.
Wolff and Hansson17 treated 74 patients with
necrotic or sloughy chronic ulcers of different aeti-
ologies and found that maggots effectively debrided
86% of the necrotic ulcers, and a single application
was clinically benecial in two-thirds of the patients.
One-quarter of the study group experienced less
pain during treatment, while 41% felt no difference
in pain, and, although 34% noted an increase in
pain, most of these patients wanted to continue the
treatment because of subjective and objective visual
improvement in wound debridement.
Steenvoorde et al.26 determined pain levels in
patients treated with MDT using a visual analogue
scale. Paracetamol (1g/3×daily) and fentanyl patch
(25μg/hour every 3days and 50μg/hour a day, before
the maggot challenge) were administered for pain
relief in the outpatient clinic. Diabetic patients expe-
rienced the same amount of pain before and during
MDT, while 8 out of 20non-diabetic patients experi-
enced more pain during MDT than before. The differ-
ence between diabetic and non-diabetic patients was
statistically signicant for all applications combined.
In 78% (n=37) of patients, pain was adequately treat-
ed with analgesic therapy. The authors came to the
conclusion that a standardised but individually
tailored pain management protocol is mandatory.
Dumville et al.27 reported that the mean ulcer-
related pain scores (for the 24hours before removal
of rst debridement treatment) for the larvae
groups were about double those of the hydrogel
group, when comparing loose larvae or bagged
larvae with hydrogel.
In our patient cohort, in general, increased pain
prior to the treatment was a risk factor for signi-
cant pain associated with MDT. Although the TBA
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JOURNAL OF WOUND CARE VOL 21, NO 8, AUGUST 2012 405
technique showed a slightly higher percentage of
increased pain compared with DA, this technique
was initially selected in those patients who reported
signicant pain before MDT was applied. Neverthe-
less, it is our clinical impression that the TBA tech-
nique causes less pain then the DA technique.
It should be taken into consideration that pain is
also a subjective symptom. Before treatment
patients were informed about the possibility that
MDT might cause pain or increase the level of exist-
ing pain. This might have inuenced some of the
patients in experiencing more pain during MDT.
We did not check the patients for other causes of
pain, such as neuropathic pain, as the patients
included in our report were all coherent and were
specically asked for MDT-associated pain. There
were no signicant differences noted in pain report-
ing by patients with diabetes compared with the rest
of the patient population.
MDT-associated pain is likely the result of mag-
gots’ movements on the wound surface, especially
as they use their two mouth hooks to pull their
body forwards, and because the cuticular layer of
their body is covered with thorn-like hairs. In addi-
tion, the secretion/excretion products of the mag-
gots, which include proteolytic enzymes, might
have an inuence on the exposed nerves and nerve
endings of an open wound.28
Several measures were taken in order to try to
prevent the induction of additional pain by MDT,
mainly to patients already suffering from intense
pain before initiation of therapy. The pain reduction
measures used included application of the maggots
for shorter periods of time, such as 6–8hours, mainly
during the daytime hours, use of the TBA rather than
the DA technique, and the application of smaller
maggots as well as a smaller number of maggots.
During early MDT treatments, our clinical impres-
sion was that in cases where a smaller number of mag-
gots was used the debridement was slower and
patients reported less severe pain. This observation
was later reinforced during the following years of
MDT. Another observation was that TBA causes less
pain than DA and, therefore, as mentioned previous-
ly, in patients suffering from intense pain before the
initiation of MDT, the TBA rather than the DA tech-
nique was used. We believe that in this manner of
application, the maggots do not irritate the exposed
nerves and nerve endings with their mouth hooks,
skin scales and hairs and, therefore, it is less painful.
Limitations
The present study had a number of limitations. As
the patients were treated in an open clinical study,
the level of pain was not routinely measured and
quantied before and during MDT, and the inter-
ventions for pain reduction were decided on sepa-
rately for each patient, without a predetermined set
of possible interventions.
Conclusion
MDT proved to be an effective method in debriding
and disinfecting chronic wounds, as well as initiating
granulation. It is a simple, efcient, safe and cost-
effective tool for the treatment of wounds and ulcers
which do not respond to conventional treatments
and surgical interventions. A full debridement is
achieved with 2–3MDT cycles, which last 3–5days.
It is therefore worthwhile having a setup that is
prepared to treat patients experiencing pain with
potent analgesics such as opioids, and in extreme
cases of severe unrelieved pain by continuous periph-
eral nerve blocks, as conventional methods would
take much longer to achieve the same result. n
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Ioffe-Uspensky, I. et al. Maggot
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