Nurse, get me the maggots, stat!

Early in my internship I cared for a young Southeast Asian man who had a rare collagen disease. Surgery for an aneurysm (weakening in the wall of a blood vessel) in his pelvis left him with a large, poorly healing wound in his lower abdomen. As the lowliest member of the surgical team, it was my job to debride his wound every day. Debriding means cleaning and carefully removing any dead tissue from a wound. It would have been a lot easier for him and for me if I had had maggots.

  maggots rulermaggots container

 Maggots weren’t available then, but they are now. In a sign that maggots have gone mainstream, the government recently announced that Medicare and Medicaid will pay for maggot therapy. This is yet another milestone in the rise, fall and resurgence of maggots in medicine.

For centuries, maggots were an important part of wound care. According to Maggot Therapy: The Science and Implication for Complementary and Alternative Medicine:

… In 1829, Baron Dominic Larrey, Napoleon’s battlefield surgeon, described how men had arrived at his field hospital with healing maggot-infested wounds. The wounds were sustained in battle, but, owing to the presence of maggots, were not infected and showed accelerated healing. Such positive accounts were made by many surgeons who followed, but it was William Baer, Professor of Orthopaedic Surgery at the John Hopkins School of Medicine .., who is believed to be the founder of modern maggot therapy.

… Baer … pioneered the use of sterile maggots as a reputable method of wound therapy, following observations he made about the value of maggots in traumatic wounds on the battlefield in France during World War 1… [B]y the mid-1930s almost 1000 North American surgeons employed maggot therapy and by the end of the decade it was in use in over 300 hospitals in the US and Canada.

Instead of daily wound cleaning and removal like my patient had to endure, wound patients had a “dose” of maggots applied to the wound and the world’s tiniest “surgeons” did the same job, slowly and without patient discomfort, working 24/7 to heal wounds in record time.

Maggot therapy came to an abrupt end in the 1940’s when antibiotics came into widespread use. Antibiotics were easier to use, extraordinarily effective at healing infected wounds, and had greater scientific glamour than the lowly maggot. In an age of increasing antibiotic resistance, and the rise of “superbugs” such as MRSA (methicillin resistant staph aureaus), maggots are making a comeback.

Of course, not any maggots will do. The larvae of Phaenicia sericata, the common green-bottle fly, is the maggot of choice. That’s because maggots can be divided into two types, those that will eat living tissue and those that can only survive on dead tissue. Phaenicia maggots belong to the second type. In a wound, they will only consume the dead tissue that is interfering with healing and leave the live tissue alone. When there is no dead tissue left and the wound is healed, they will simply move on.

Maggots have some terrific advantages in wound healing. First, they seem to be able to do the job when all else fails. In Maggot debridement therapy of infected ulcers: patient and wound factors influencing outcome – a study on 101 patients with 117 wounds, the authors report:

It has been known for centuries that maggots are potent debriding agents capable of removing necrotic tissue and slough. … [W]e performed a prospective study to gain more insight in patient and wound characteristics influencing outcome…

… In total, 78 of 116 wounds (67%) had a successful outcome. These wounds healed completely (n = 60), healed almost completely (n = 12) or were clean at least (n = 6) at last follow-up. These results seem to be in line with those in the literature. All wounds with a traumatic origin (n = 24) healed completely… Outcome was not influenced by gender, obesity, diabetes mellitus, smoking, ASA-classification [wound severity], location of the wound, wound size or wound duration.

Second, maggots are effective when antibiotics fail. In the age of the “superbug,” bacteria that are resistant to multiple powerful antibiotics, maggots can still get the job done. Recent research has shown that maggots are just as effective in cleaning wounds caused by MRSA as they are at cleaning wounds caused by other bacteria. When the maggots remove the dead tissue, the body can heal the infection itself.

Third, using maggots to treat routine wounds instead of the current treatment with antibiotics would slow the rise of new drug resistant bacteria.

Finally, maggot therapy is much less expensive than conventional antibiotic therapy. A supply of “medical maggots” from Monarch Labs costs less than $100, in contrast to thousands of dollars for a course of powerful antibiotics. Maggots often work faster than antibiotics, reducing hospitalization costs. When you consider that maggots can prevent the need for amputation of limbs, a course of maggot therapy can save tens of thousands of dollars.

It’s not everyday that scientists discover a new treatment that is effective, easy to use, impervious to antibiotic resistance and inexpensive. The maggot, only recently relegated to the medical sidelines, is poised regain respect. That’s seems only fitting for what are, in truth, the world’s tiniest surgeons.

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