Maggots - Julie Jones

8/10/2019 Maggots - Julie Jones

http://slidepdf.com/reader/full/maggots-julie-jones 1/6

CLINICAL FOCUS

S24 Wound Care, March 2011

Chronic wounds can be defined as those which do

not heal progressively through a set of particular

stages, hence failing to provide an anticipated

recovery time. Many chronic wounds still require treat-

ment after three months has lapsed (Ayello and Cuddigan,

2004; Benbow, 2007). These chronic wounds place a huge

burden upon the already stretched resources of the NHS,

especially where such wounds present as chronic venousleg ulcers (Harding et al, 2002).

Leg ulcers caused by chronic venous insufficiency affect a

great many of the population; approximately 1-2 people out

of every 1000 of people at any one time; with around 10-20

people out of every 1000 experiencing this at least once

(Bergan et al, 2006; Posnett and Franks, 2008). Ulcer healing

rates are notoriously poor; with around 50% still remaining

unhealed and requiring ongoing treatment some 9 months

after diagnosis. Recurrences are common; with one third

of those currently being treated suffering their fourth or

more event. (Bergan et al, 2006). This being the case, 1.3%

of the whole healthcare expenditure is concentrated on

ulcer management in the UK, with 90% of those affected

being treated within the community setting. The total cost

each year to the NHS is estimated within the region of

£200 million per year (Posnett and Franks, 2007).

The primary purpose of maggot therapy is the break-

down of necrotic tissue within a chronic wound, which will

then transform into an acute wound; subsequently begin-

ning 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 dat-ing back to Napoleonic times. Today, this treatment has

a growing popularity and specially constructed laborato-

ries 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 deb-

ridement, it still remains cosmetically unappealing to themajority 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 man-

agement of chronic wounds (Sherman, 2005), many areas

for improvement surrounding maggot therapy were identi-

fied via analysis of literature on the subject.

Literature searchSearch strategyA search strategy was used to identify both empirical and

theoretical literature using the aforementioned keywords;

larval therapy, maggot therapy, chronic wounds, leg ulcers

and infected wound management. This search encompassed

Maggots and their rolein wound care

Julie Jones, Julie Green and Alison Kate Lillie Julie Jones, written during f inal year of B.Sc (Hons) Adult Nursing, Julie Green, Lecturer in Nursing, Keele University, AlisonKate Lillie, PhD Lecturer in Nursing, Keele University Email: [email protected]

ABSTRACTLeg ulcers caused by chronic venous insufficiency affect a great many

of the population, costing the NHS an estimated £200 million per year.

The clinical use of sterile maggots under the brand name LarveE has

increased steadily in the UK since they were introduced in the UK in

late 1995. Maggot therapy breaks down necrotic tissue within a chronic

wound, transforming it into an acute wound; subsequently beginning

the healing process a lot quicker, thus reducing overall costs to the

National Health Service. A literature review was conducted on studies

that explored the use of maggot therapy in the management of chronic

wounds. Four key themes were identified and analysed from this search,

including infection control, promotion of healing, cost-effectiveness and

the ‘yuk’ factor.

KEY WORDSw Larval therapy w Maggot therapy w Chronic wounds w Leg ulcers w

Wound debridement w Infected wound management



CLINICAL FOCUS


books, internet, and electronic sources to ensure only the

most up to date, relevant information was accessed.

Relevant databases were selected and searched; those

being British Nursing Index, CINAHL, EMBASE,

MEDLINE, The Cochrane Library and GOOGLE Scholar.

The following search words were used: ‘Chronic

wounds’, ‘Larval therapy’, ‘Maggot therapy’, ‘Leg ulcer’,

‘Wound debride’, ‘Wound manage’.

Additional data was also collated via hand-searching rel-

evant journals at the Keele University Clinical Education

Centre, and via reference list/author searching. In addition,

supporting evidence has been gathered from experts in the

field of wounds, such as ‘BioMonde’, ‘Smith and Nephew’

and ‘World Wide Wounds’. This was achieved through an

accumulation of postal correspondence, emails and internet

access to their corresponding websites; which allowed the

authors to gather information relating to the clinical pro-

duction and use of sterile larvae in chronic wound therapy.Specialist practitioners such as the tissue viability nurses

(TVNs) and wound care representatives via the community

setting have also been contacted, to provide further sup-

porting information and evidence.

Search resultsTable 2 lists the numbers of results gained from the vary-

ing 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 AppraisalSkills 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 controlChronic wounds are notoriously prone to infections such

as Methicillin-resistant Staphylococcus aureus (MRSA) or

other hospital acquired pathogens such as Pseudomonas,

and the resulting aggressive long, drawn out treatment with

antibiotics and topical applications, and the isolation of the

patient who may contract further infection, can incur great

costs for care, bed days and nurses’ time (Beasely, 2004).

However, maggots are known to secrete proteolytic

enzymes including collagenase (Ziffren et al, 1953) and

enzymes resembling trypsin and chymotrypsin (Chambers,

2003), which aid absorption of dead tissue and bacteria;

where the bacteria is then destroyed as it passes through

their digestive system (Steenvoorde, 2005). With this inmind, but also the knowledge that much evidence is con-

sidered anecdotal or only that contained in case reports

(Courtenay, 1999; Dissemond, 2002), a number of stud-

ies have been carried out that have confirmed that all

micro organisms were eradicated within 10-15 minutes of

ingestion by the maggot (Robinson and Norwood, 1934;

Simmons, 1935; Lappin-Scott, 1998; Mumcuoglu et al,

2001).

A further study by Courtenay et al (2000) concluded that

maggot therapy is an extremely efficient alternative option

for fast and efficient wound management, often prevent-

ing major surgery, and an excellent ally in the fight against

antibiotic-resistant infection. All the literature reviewed in

Figure 1. BioFOAM dressings contain products that support and stimulatemaggot activity, while containing exudates

Figure 2. Maggots are available ‘free-range’, they are supplied in a clearcontainer and placed directly onto to wound



CLINICAL FOCUS


this section indicated that maggot therapy was not only

instrumental in reducing bacteria levels, thus infection, but

also in reducing unpleasant odours and pain (Robinson

and Norwood, 1934; Simmons, 1935; Lappin-Scott, 1998;Courtenay et al, 2000; Steenvoorde et al, 2007).

Promotion of healingA chronic wound is one which is non-healing and often

incorporates bacteria-laden slough, which has to be debri-

ded 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, mini-

mizes and eliminates factors which adversely effect wound

healing (Cutting et al, 2002).

Wound healing includes four stages; haemostasis, inflam-

mation, proliferation and maturation, occurring independ-

ently 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 incomparison to hydrogel, a standard debridement treat-

ment

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 mag-

got 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

experienced by the participants did appear to increase.

Despite this study having several limitations, the sample

size was relatively large in comparison to other studies,

which supports generalizability and reliability of the find-

ings (Cormack, 2000).

A further study by Sherman (2003) also established theefficiency of maggots as a debridement technique, which

supports findings from the ‘VenUS II Trial’. However, the

sample was notably small and thus did not support gen-

eralizability and reliability of the findings, which may be

deemed a limitation (Cormack, 2000).

All literature reviewed in this section indicated that

maggot therapy did indeed hasten debridement of necrot-

ic tissue from chronic wounds, and encouraged swift

granulation in comparison with conventional treatments,

culminating in greatly improved chronic wound healing

(Sherman, 2003; Acton, 2007; BioMonde, 2010).

Cost-effectivenessApproximately 200 000 people each year in the United

Kingdom suffer from chronic wounds at any one time,

costing the NHS in excess of £2.3bn–3.1bn per year to

care for them (Posnett and Franks, 2008). As a result, a

number of studies to assess the cost effectiveness of mag-

got 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 hadoccurred, 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 requir ing

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,

Table 2.

Database Number of arti-

cles

British Nursing Index 11

CINAHL 45EMBASE 15

MEDLINE 2

The Cochrane Library 12

Google Scholar 6

Pubmed 15

Table 1. Inclusion/exclusion criteria

Inclusion criteria Exclusion criteria

Research available inEnglish

Research not avail-able in English

Published since 1995 Research prior to1995

Adult patients aged 18+ Paediatric patients

Chronic wounds Acute wounds

Primary care focus Secondary carefocus

Published research Unpublishedresearch



CLINICAL FOCUS


and in addition to this the small sample size rendered the

study questionable of generalizability (Cormack, 2000).

However, Wayman et al (2000) does acknowledge these

limitations, and recognized the need for a larger study.

Following the review of cost-effectiveness literature,

while a single application of maggot therapy may initiallybe more costly than the hydrogel, results indicate that

reduced healing time, nursing visits and applications within

the maggot therapy group contributed to less cost overall,

suggesting that maggot therapy may ultimately be more

cost effective than standard debridement treatments.

The ‘yuk’ factor Just mentioning word ‘maggots’ generates repugnant imag-

es of infested, rotting food, or worse still, decaying flesh,

so it is not surprising that the thought of placing these

creatures on infected wounds is often an unattractive and

unbearable consideration for many patients suffering with

chronic wounds. This is deemed the ‘yuk factor’ (Evans,2002; Sherman, 2003).

There is limited literature on patient experiences of

maggot therapy, and so to try and determine the extent

of this ‘yuk factor’, Kitching (2004) carried out a phe-

nomenological study on 6 patients over a 12-week period

suffering from severe symptoms related to their chronic

wounds. Despite patients’ initial misgivings and negative

preconceived ideas surrounding maggot therapy; those

being that they are ‘dirty creepy crawlies, crawling inside

their wound’, and one patient even requesting a general

anaesthetic while having treatment.

Following the provision of clear information and subse-

quent therapy, five out of six patients were pleasantly sur-

prised that it was not as unpalatable as they had suspected

it to be, and that their wounds had improved overall with

very little or no pain (Kitching, 2004).

Kitching (2004) acknowledged the limitations in the

study being of uneven sampling, with a ratio of 5:1,

women to men, and while being a very small sample of six,

which limits validity (Cormack, 2000). However, Kitching

concluded that the study did appear to establish that pro-

viding all negative issues surrounding maggot therapy are

addressed with each patient, then it may no longer prove

unacceptable to them (Kitching, 2004).

A later study by Steenvorde (2005) supported these

findings, which was centred upon 41 patients with non-

healing 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 medicalcare, 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 influ-

ence patient choice with good quality information and

honest communication (Courtenay et al, 2000; Thomas,

2001; Jukema et al, 2002; Sherman, 2003).

Conclusion and recommendationsThere is a common opinion that much more research is

needed in this area (Thomas et al, 2003; White 2005), as

clinical trials involving maggot therapy are somewhat lim-

ited, and now, more than ever, evidence warrants further

investigations (Sherman, 2002), particularly in view of the

fact that qualified practitioners rely heavily upon clinical

trials to provide the evidence base which rationalizes their

adoption and use of new treatments and interventions

(Venlcatramam et al, 2002).

Improved clinical trials are needed to assess the effective-

ness of maggot therapy while treating all chronic wounds,

including pressure ulcers, venous stasis ulcers, diabetic foot

ulcers, burns and post-surgery wounds, when compared to



CLINICAL FOCUS


conservative medical treatments and surgical debridement.

Moreover, RCTs are considered to be ‘gold standard’ in

terms of research, and in demonstrating the effectiveness

of a particular treatment/intervention in a very rigorous,

scientific approach (Cormack, 2000; NICE, 2000).

Further studies to ascertain the overall cost effectiveness

of maggot therapy will also be invaluable, to establish the

optimum time scale of use of maggot dressings, and alsothe impact of maggot therapy on infection control issues,

i.e. the avoidance/reduction of wound infections such as

MRSA, possibly culminating in the need for antibiotics

and analgesia, and avoidable, costly hospital admissions.

The statistics from studies such as these and those reflecting

the current extent and cost of caring for patients’ chronic

wounds, will serve to support and encourage the drive to

discover swift and effective wound healing methods, which

will undoubtedly reduce the present burden upon health

professionals and the NHS in general (NICE, 2000).

A need is also recognized for more qualitative studies, to

establish if a negative preconceived image of maggot ther-

apy, namely the ‘yuk factor’, indeed has a detrimental effect

upon the patient or qualified practitioner when deciding

upon a wound management strategy. Further studies will

also ascertain whether a negative attitude towards maggot

therapy held within the clinical environment has greater

far-reaching effects, in that it actually prevents promotion

of the therapy altogether. It is believed that more detailed

qualitative studies could substantially improve acceptability

levels of maggot therapy (Mumcuoglu et al, 2001).

Education and training for staff surrounding maggot

therapy is considered essential in order to break down

these barriers associated with the ‘yuk factor’. One of the

greatest fears for those contemplating maggot therapy isthat of the maggot possibly turning into a fly while in

the wound. It is imperative, therefore that nurses gain a

full understanding of the life cycle of the maggot in order

to be able to reassure the patient with confidence. Other

information that nurses need to be familiar with include

the mechanism of maggot debridement, the different

applications available, maintenance of the dressing and

possible side-effects associated with the therapy, i.e. tin-

gling sensation, pain, bleeding and increased exudate. It is

imperative that the nurse is knowledgeable in order to pass

on this information and gain full consent from the patient.

Of course a great deal more knowledge can be absorbed

with proper education. However, it would be extremely

costly to train all qualified nurses on a one-to-one basis, and

so it is suggested that the cascading of information by suit-

ably trained link nurses and use of company nurse advisors

may be a route to follow. In addition, explicit, informative

leaflets could be made available for all nurses, and specially

trained TVNs could be the ones to actually suggest and ini-tiate the treatment, and then be available to offer advice and

guidance to nurses and patients alike, regarding all aspects of

maggot therapy as the treatment progresses.

In addition, modified information leaflets could be dis-

tributed to patients themselves considering maggot therapy,

which address many key issues relating to the patient’s

experience of maggot therapy as we know it, i.e. the differ-

ent modes of application, reassurance that the maggots will

not lay eggs or burrow healthy tissue, possible side effects,

and that the patient can continue pretty much with his or

her normal routine. Leaflets provided by a trusted supplier

of the larvae such as BioMonde would serve to ensure

consistency of information to patients and thus serve toalleviate some of the stress and concerns that the patient

may be feeling. In addition, the TVN involved in their

treatment can further reassure and support the patient in

their decision making.

Ultimately, a push for more RCTs (a number of which

are currently being undertaken, although the development

of which can be difficult) to establish the appropriateness

of maggot therapy for use in the clinical environment,

such as the well known VenUSII trial (Dumville, 2009), its

cost effectiveness and its safety and quality, combined with

education and evidence-based practice, will support and

encourage the inclusion of maggot therapy in the drug

tariff. This would potentially result in it being more readily

and widely prescribed in the future, as it could be argued

that a drug tariff without a full spectrum of products com-

promises the care of patients (Millard, 2002).

To conclude, the above recommendations are considered

to be basic and achievable within our current NHS envi-

ronment, with any initial costs incurred almost certainly

recuperated quickly with the growing use of maggot ther-

apy and thus costs saved by the divergence from alternative,

more expensive treatments. The implementation of these

recommendations will serve to promote maggot therapy

as the cost-effective, efficient, patient-friendly method of

chronic wound management that it is proven to be, so thatit can be widely adopted as a safe, efficient, contributor to

chronic wound healing. BJCN

Acton C (2007) A know how guide to using larval therapy for wound debride-

ment. Wound Essentials 2: 156-9

Ayello E, Cuddigan J (2004) Debridement: Controlling the necrotic cellular

burden. Advances in Skin and Wound Care 17(2): 66-76

Beasley W, Hirst G (2004). Making a meal of MRSA-the role of bio-surgery in

hospital-acquired infection. Journal of Hospital Infections 56(1): 6-9

Benbow M (2007) Healing and wound classification. Journal of Community

Nursing 21(9): 26-32

Bergan J et al. (2006) Chronic venous disease. New England Journal of Medicine

355:488-98

BioMonde (formerly ZooBiotic) (2010) BioSurgical Research Unit. Bridgend.

South Wales. Accessed 18/05/10 from: www.BioMonde.co.uk

Chambers L, Woodrow S, Brown A (2003). Degradation of extracellular matr ix

KEY POINTSw 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.



Wound Care, March 2011 S33

CLINICAL FOCUS

Robinson W, Norwood V (1934). Destruction of pyogenic bacteria in the

alimentary tract of surgical maggots implanted in infected wounds. Journal

of Laboratory Clinical Medicine 34: 581-6 Royal Pharmaceutical Society of

Great Britain (2009) Law and Ethics Bulletin: Prescribing of unlicensed medicines

by Pharmacist and Nurse Independent Prescribers. www.rpsgb.org.uk/pdfs/

LEBunlicensedmed.pdf (Accessed 21 February 2011)

Sherman R (2002) Maggot vs. Conservative debridement therapy for the treat-

ment of pressure ulcers. Wound Repair and Regeneration 10 (4): 208-14

Sherman RA (2003) Maggot therapy for treating diabetic foot ulcers, unrespon-

sive to conventional therapy. Diabetes Care 26(2): 446-53

Sherman R (2005). Age-old therapy gets new approval. Adv Skin Wound Care

18(1): 12-15

Shipperely T, Martin C (2002). The physiology of wound healing:an emergency

response. Nursing Times 98(8): 54

Simmons S W (1935) The bactericidal properties of excretions of the maggot of

Lucilia ser icata. Bull.Entomological Research 26: 559-63

Steenvoorde P (2005) Maggot debridement therapy: free range or contained?

An in-vivo study. Advances in Skin and Wound Care 8(18): 430-5

Steenvorde P, Van Doorn , Jacobi C, Oskam J (2007) Maggot debridement

therapy in the palliative setting. American Journal of Hospital Palliative Care

24(4): 308-10

Thomas S, Jones M, Shulter S, Jones S (1996). Using larvae in modern wound

management. Journal of Wound Care 5(2): 60-9

Thomas S, Banks V, Bale S (1997) A comparison of two dressings in the manage-

ment of chronic wounds. Journal of Woundcare 6(8): 383-6

Thomas S, Jones M (2000) Maggots can benefit patients with MRSA. Practice

Nurse 2(20): 101–4

Thomas S (2001) New hope from old therapy, maggots in wound care. Nursing

in Practice Winter: 103-6

Thomas S, Wynn K, Jones M (2003). The effect of containment of the properties

of sterile maggots. Journal of Tissue Viability 11(12): 46-8

Timmons J (2006) Skin function and wound healing physiology. Wound

Essentials 5(1): 8-17

Timmons J (2007). The importance of a patient-centred approach to care.

Wounds UK 3(4): 6-7

University Hospital of North Staffordshire (2001) Tissue Viability Guidelines.

NHS Trust, Stoke–on–Trent

Venlcatraman P, Anand S, Dean C, Nettleton R (2002) Clinical trials in wound

care II: Achieving statistical significance. Journal of Wound Care 11

(4): 156-60

Wayman J, Nirojogi V, Walker A, Sowinski A, Walker M, (2000) The cost effec-

tiveness of larval therapy in venous ulcers. Journal of Tissue Viability 10: 91-6

White R (2005) Trends in woundcare . Quay Books, Salisbury

Wound Care Formulary (2001) Newcastle-Under-Lyme Primary Care Group,

Stoke-on-Trent

Ziffren S, Heist H, May N, Womack S (1953) The secretion of collagenase by

maggots and its implications. Annual Surgery 138: 932–4

components by defined proteinases from the greenbottle larva: Lucilia seri-

cata used for the clini cal debridement of non-healing wounds.British Journal

of Dermatology 148: 14–23

Collier R, (2010). New interest in maggot therapy. Canadian Medical Association

Journal 182(2): 121–2

Cormack D (2000) The Research Process in Nursing . Blackwell Science, Oxford.

Courtenay, M. (1999). The use of larval therapy in wound management in the

UK. Journal of Wound Care 8: 177–80

Courtenay, M., et al (2000). Larval therapy in wound management. Journal of the

Royal Society of Medicine 93: 72-4

Cutting K, Tong A (2002) Wound Physiology and Moist Wound Healing . J&J

Wound Management. Medical Communications UK Ltd, London

Dissemond J, Koppermann M, Esser S, Schultewolter T, Goos M, Wagner S

(2002) Treatment of methicillin-resistant Staphylococcus aureus (MRSA) as

part of biosurgical management of a chronic leg ulcer. Hautarzt 53: 608–12

Dumville J et al (2009) Larval therapy for leg ulcers (VenUS II): randomised

controlled trial. British Medical Journal 338: b773

Evans P (2002). Larvae therapy and venous leg ulcers: reducing the ‘yuk factor’.

Journal of Wound Care 11: 407-8

Harding K, Morri s, H, Patel G (2002). Healing chronic wounds.British Medical

Journal 324: 160-3

Jones M, Andrews A (1998) Wound management: Theory and practice. Emap

Healthcare Ltd, London

Jukema G, Menon A, Bernards A, Steenvorde P, Rastegar A, Van Dissel J (2002)Amputation-sparing treatment by nature: ‘surgical’ maggots revisited.Clinical

Infectious Diseases 35: 1566-71

Kitching M (2004) Patients perceptions and experiences of larval therapy.

Journal of Wound Care 13(1): 25-9

Knowles A, Findlow A, Jackson N (2002) Management of a diabetic foot ulcer

using larval therapy. Nursing Standard 16(6):73-6

Lappin-Scott H (1998) Bacterial-maggot interactions in wound therapy. Third

International Conference on Biotherapy, Jerusalem, Israel.

Millard D (2002) Larval Therapy: A case for inclusion in the Drug Tariff.Nursing

Times Plus 98(36): 48-9

Mumcuoglu K, Miller J, Mumcuoglu M, Friger M, Tarshis M (2001)

Destruction of bacteria in the digestive tract of the maggot of Lucilia sericata

(Diptera: Calliphor idae). Journal of Medical Etomology 38(2): 161-6

National Institute for Health and Clinical Excellence (2000) A rapid systematic

review of the clinical effectiveness and cost effectiveness of debriding agents in treat-

ing surgical wounds by secondary intention. NICE, London. http://tinyurl.

com/6887zh4 (Accessed 21 February 2011)National Institute for Clinical Excellence, (2001) Guidance on the use of debriding

agents and specialist wound care clinics for difficult to heal surgical wounds. NICE,

London. http://tinyurl.com/69hx7ja (Accessed 21 February 2011)

Public Health Resource Unit (2006) Critical Appraisal Skills Programme (CASP):

making sense of evidence. Public Health Resource Unit, England

Posnett J, Franks P (2008). The burden of chronic wounds in the UK. Nursing

Times 104(3): 44-5

Maggots - Julie Jones

Documents

Transcript of Maggots - Julie Jones