VOL: 100, ISSUE: 14, PAGE NO: 48
Mair Fear, RGN, DNDip, ADNS, is clinical nurse specialist in tissue viability, Plymouth Teaching Primary Care Trust
Most of these patients were treated in hospital because of problems with funding the treatment in the community. However, some centres managed to obtain budgets for the purchase of maggots from their local primary care trust.
While sterile maggots were not available on prescription, some patients were inevitably denied this form of treatment. The recent addition of sterile maggots to the list of prescription-only items means that patients in the community can now benefit from this unconventional but highly effective therapy.
The tissue viability service in Plymouth Teaching Primary Care Trust (tPCT) has held a budget to provide maggots in the community for the past four years (Fear et al, 2003). This article aims to share information with colleagues who may not have used maggots previously.
With the advent of a new dynamic therapy, there is the possibility of inappropriate and uncontrolled use, which can lead to it being withdrawn or not being added to formularies or guidelines.
In the Plymouth tPCT formulary, maggot therapy is identified as for ‘specialist use only’. This means practitioners must ensure they understand the purpose of the treatment and how to apply, maintain and remove the maggots. Established protocols can be found on the Biosurgical Research Unit’s website (www.larve.com).
How many are needed - The number of pots of maggots needed for each application depends on the size of the particular wound and the amount of slough present. A calculator is available (Box 1) and can be obtained from the Biosurgical Research Unit, which supplies maggots.
Starting therapy - A GP prescription is required to order maggots in the community. The maggots are supplied in sterile pots, each containing about 300. Each pot has a cap with a membrane filter that allows the passage of air but prevents the transmission of micro-organisms.
The ‘free-range’ maggots are retained in the wound with a piece of fine nylon mesh (LarvE Net) that is supplied with each consignment of maggots. For larger wounds on the leg or foot, the net is supplied in the form of a sleeve or boot that covers the entire area of the wound. A half-boot is available for toes and amputation wounds. Full details of the LarvE product range together with prices are shown in Box 2.
Application of the maggots is not difficult but does require an element of dexterity and patience to ensure they remain in the net. A useful tip is to moisten the net before pouring out the maggots. This helps to contain them in the centre of the dressing.
Maintenance - Maggots need moisture, air and food to survive. Enclosed dressings or a lack of moisture in a warm environment can result in the maggots drying out. Patients or relatives are in the best position to ensure survival of the maggots, and achieving concordance and good communication are important factors in fulfilling this objective.
Patients should be told that the therapy entails the use of maggots. Health care professionals should avoid the use of words that will be unfamiliar to patients, such as ‘larval’ or ‘biosurgical’ intervention.
It is important to explain to patients that when maggots are used the exudate from the wound will be red and bloody, and that this is a positive rather than a negative result. Patients need support during therapy and a contact number they can ring if they have any questions is always appreciated.
Disposal - Used maggots, like any other used dressing material, are potentially contaminated with bacteria and classified as clinical waste. In the community setting it is the responsibility of the clinician to ensure that such waste is disposed of in accordance with the local health regulations.
To transport it without using the approved method or container is in conflict with Statutory Instrument 1996 No. 2092: The Carriage of Dangerous Goods (Classification, Packaging and Labelling) and Use of Transportable Pressure Receptacles Regulations 1996. To avoid this, Plymouth tPCT policy insists on the use of burn or sharps bins.
To address concerns about disposal, the Biosurgical Research Unit has developed a distribution system that also acts as a disposal container for used maggots and associated clinical waste (Fig 1). It consists of a resealable box with a removable outer sleeve.
For distribution purposes, the box contains the maggots and retention net. Once the outer sleeve is removed, both markings and instructions identify that the box has been independently tested and approved for the transportation of clinical waste. Clinicians can transport this container in their cars to an approved collection point.
Edward Wilson had a below-knee amputation. The wound dehisced (opened) and became colonised with methicillin-resistant Staphylococcus aureus (MRSA). The advice from his surgical team was to have an above-knee amputation and he returned home to consider his options.
The application of maggots was discussed with Mr Wilson. With some reservations, he agreed to this. The first application of maggots took place in August 2003 (Fig 2). While there was no adverse reaction to the maggots, there was some discomfort from the hydrocolloid dressing used around the wound. This was addressed by removing the maggots after two days instead of three.
It took three cycles of treatment before a silver impregnated hydrofibre dressing was used (Fig 3).
When most of the wound bed had been prepared, healing took place despite the presence of an area of exposed bone. The surgical team reviewed the limb and still recommended further amputation. This was discussed with Mr Wilson, his GP, his family, and the team of nurses caring for him in the community.
It was decided to proceed with conservative treatment and assess how healing progressed. Fig 4 shows the wound in January 2004. Exposed bone was still visible, but the consultant decided that it could be refashioned to preserve the lower part of the limb and facilitate the use of Mr Wilson’s prosthesis. The wound still remained infected with MRSA but continued to heal as the bacterial proliferation had been reduced.
When we asked Mr Wilson for permission to use his photographs and care programme, he said: ‘As patients, we are afraid of things that we are not used to, we get the wrong idea.
‘If they are explained and we are given choices it is far better. I have no doubt that if I hadn’t had the maggots, I would have lost more of my limb. Things have not been plain sailing for me but what I have left of my limb I will keep.’
Maggot therapy does not simply prove to be of benefit to patients cared for by community and practice nurses but has implications for podiatry and treatment centres.
As practitioners we have to ensure that we have selected the right patient and the right wound for the application of maggots. Currently the tissue viability service within Plymouth Teaching PCT is contacting GPs to offer support, guidance and information if they are asked to prescribe maggots. We want this procedure to be used effectively, efficiently, and appropriately.