Maggot Bio-Debridement Therapy for Diabetic Foot ulcers–Literature Review

Diabetic foot ulcers are chronic, difficult to treat wounds that are associated with high morbidity andmortality. Several therapies have been proposed as adjuncts to the traditional wound care, among them is the maggot debridement therapy (MDT). MDT had been used for decades for treating non-healing wounds. However, with the beginning of the antibiotic era, itsuse had gradually faded. In the last years, MDT has re-emergedin clinical use, mainly because of the rise of anti-microbial resistance. Herein we summarize the last decade accumulated data on the clinical implication of the treatment by maggot debridement for non-healingdiabetic foot ulcers. 1Department of Internal Medicine C, Beilinson Hospital, Rabin Medical Center, Petah Tiqvaand Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv , Israel. *Corresponding author Alaa Atamna, MD. Department of Internal Medicine “C”, Rabin Medical Center; Beilinson Hospital, Petah-Tiqva, 49100, Israel, E-mail: [email protected]. Submitted: 30 June 2017; Accepted: 07 Aug 2017; Published: 14 Aug 2017 Case presentation A 67-year-old patientwas admitted because of long standing infected foot ulcer. His medical history includedpoorly controlleddiabetes mellitus, hypertension and hyperlipidemia, for which he was treated by Metformin, Glargine insulin, Enalapril and Atorvastatin. On admission: body temperature was 36.4 C, blood pressure 130/70 mmHg, heart, lungs and abdominal examination was unremarkable, peripheral pulses were intact, there was a 4cmX3cm ulcer at the planter aspect of the right foot, with worm and hyperemic area surrounding it. Signs of osteomyelitis werenot detected on foot X-RAY. Laboratory results revealed: white blood cells13000/mm3, Hemoglobin 13.0 g/dl, platelets 350000/ mm3, CRP 5.0 mg/dl, and glucose 175 mg/dl, kidney, liver function tests and electrolytes were normal,hemoglobin A1C 8.4%. An ankle brachial index and continuous wave doppler analysis were reported normal two month prior to admission. During the last year, he had repeatedsurgical debridement manipulations with concomitantempiric antibioticcourses,followed by10 sessions of hyperbaric oxygen therapy, all without any improvement. An adjuvant therapy by maggot debridement therapy (MDT) was suggested. Three cycles of MDT were applied; each cycle lasted for 3 days. A great improvement was noticed in wound healing after 10 days of MDT. Introduction Diabetic foot ulcers are chronic, difficult to treat wounds that are associated with high morbidity and mortality. They are considered the most common admission diagnosis for diabetic patients in the developed world [1]. Multiple factors are involved in the etiology of diabetic foot ulcers, including peripheral neuropathy, external trauma and peripheral vascular diseases [2]. Several therapies have been proposed as adjuncts to the classic triad of diabetic foot ulcer management-medical therapy (glycemic control and antibiotic treatment), revascularization, and surgical debridement, includingvacuum assisted wound closure, hyperbaric oxygen therapy, growth factors, and MDT. MDT is an old-new treatment modality, whichwas approved by the FDA in 2004, as a medical device indicated for treating chronic non-healing wounds [3]. Herein we summarize the accumulated data in the last decade’s literature on the clinical implication of MDT for diabetic non-healingfoot wounds. Historical perspective MDT is an old technique in wound care, one of the first written reports on larval therapy and its beneficial effects in the wounds of soldier’s date back to 1557 which is credited to Ambroise Paré, a chief surgeon to France’s Charles IX and Henri III andduring the Civil War (18611865) when, Confederate surgeons Joseph Jones and J.F. Zacharias began using maggots to treat wounds. MDT was strongly implicated in clinical use after the World War I, when Dr. William S. Baer (18721931) an American military surgeon noticed that the wounds whowere swarmed with maggots had a pink granulation tissue without any sign of systemic infection. Further he used the technique to treatchronic osteomyelitis with great response. In addition, Baer and his colleagues Fine and Alexander had developed a method for growing maggots in a sterile environment. With the introduction of the antibiotic erathe technique was gradually neglected and its use fadedgradually [4-9]. The larvae life cycle MDT uses sterile larvae of the common green bottle fly, (Phaeniciasericata) that are raised under controlled clinical conditions. Phaeniciasericata belongs to the Diptera order of insects that are able to