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Maggot Therapy in Healing Wounds



Abstract

There is renewed interest in maggot therapy in the recent past owing to the need to treat chronic wounds effectively. This increased interest is coming at a time when antibiotics fail and diabetic as well as nephritic wounds become common because of the changing lifestyles. Description of maggot therapy for healing of wounds is given in this paper as a clinical issue of concern. Critical analysis of sources of evidence and databases accessed is also given with the aim of establishing the level of evidence as it applies to the articles. The paper also offers a critical analysis of maggot therapy, its applications and recommendations for best practice in wound healing. A discussion on the applicability of recommendations to New Zealand health care sector and also the limitations that come with this kind of therapy in the country.

Keywords: maggot therapy, wounds, diabetic wounds, pressure ulcers, necrotic tissue, antibiotics

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Introduction

The dynamics of current nursing has led to transformations in the practice of nursing with many professionals required to provide evidence of how they provide treatment to their patients. This is after the realization that nurses can no longer rely on what they learnt in class for better nursing practices but rather use evidence based practice as a way of providing efficient services to clients. By utilizing evidence based practice (EBP) doctors and nurses involved in the treatment of wounds are now able to provide actual and solid reasons for providing particular services to a patient and can explain as well as justify their actions whenever they are required to do so by any authority. As argued by proponents of EBP, physicians who have adopted it in their professional practice are able to get rid of the old and ineffective practices in nursing since it views health care as a progressive process (Courtney & McCutcheon, 2010).

The Treatment of Wounds and Maggot Therapy

The treatment of wounds such as leg ulcers, pressure ulcers and diabetic ulcers can be expensive and sometimes complicated because of their necrotic tissues. For almost a century, surgeons and dermatologists used maggot therapy to treat non-healing wounds. Although the therapy received some setback on the introduction of antibiotics during the Second World War, maggot therapy is in the recent time being embraced by many countries around the world to heal wounds. The aim of this paper is to present a literature review that identifies maggot therapy for wound healing as an important nursing practice in the modern treatment of wounds. The beginning of this paper provides a background of maggot therapy and will discuss and search the strategy used, as well as the criteria for selection of articles and resources for review. The paper also offers a critical analysis of maggot therapy, its applications and recommendations for best practice in wound healing. The discussion on applicability of recommendations to New Zealand health care sector and also the limitations that come with this kind of therapy in the country will be given in relation to EBP principles. The paper concludes with a suggestion for further research and a wind up of major points discussed.

Goel, Bellovich & McCullough (2011) define maggot therapy, commonly known as maggot debridement therapy, as a type of biotherapy that involves introducing of live and disinfected maggots in a non healing tissue of the wound with the aim of cleaning out the dead tissue. The practice has a long historical background with changing perspectives regarding the earlier belief that maggots were selective of the tissue in the wound. However, recent studies suggest that with time, maggots can consume live tissue as opposed to necrotic one. Clinical findings show that certain types of maggots are capable of munching dead tissue while leaving healthy tissues in a wound. This leaves the wound clean and allows the live tissues to emerge and cover the wound without the possibility of infection. The clinical process of introducing maggots in human for purposes of treatment is known as myiasis and can be beneficial or harmful depending on particular conditions like the type of the wound and maggot. Medically, the beneficial use of maggots, which is a common practice in many countries including New Zealand, is known as maggot debridement therapy, and is a recommended therapy for non-healing wounds (Mani & Teot, 2010).

Maggots for wound healing act within some parameters including the debridement of the wound through dissolving of dead and infected tissues in the wound. This is done when maggots feed on the necrotic and infected tissue leaving out the live and healthy tissue in the wound. They also disinfect the wound by secreting substances that kill bacteria in the wound. Finally, maggots accelerate the process of wound healing through stimulation of granulation tissue production upon the removal of all necrotic and infected tissue in the wound (Whitaker, Twine & Shandall, 2007). The medical practice involves the mixing of maggot in the wound and dressing that affected area with gauze to allow the entry of fresh air. The maggots are then removed after two to three days and new ones introduced until the wound is completely cleaned off the dead tissue.

With the development of resistance to anti-biotic by some bacteria and making wound healing an almost impossible practice, the application of maggot therapy has tremendously increased in the recent past. There are 1000 centers in the UK and Europe and 300 in the US practicing maggot therapy for wound healing (Broussard & Gloeckner, 2013). However, despite the growing evidence that maggot therapy is superior to anti-biotic in the care and treatment of non-healing wounds, there has been hesitation from both doctors and patients to try the therapy owing to the nature of dealing with live maggots in a wound. Most patients and even doctors tend to associate the presence of maggots in a wound with unhealthy and sometimes will use disinfectants to remove the maggots even where the therapy is a natural process of the body (Theoret & Wilmink, 2013).

During his study, Collier (2010) noted that the hierarchy of research evidence is as follows: systematic reviews of randomised controlled trails or clinical guidelines based on systematic reviews is a level 1 evidence; and one or more randomised controlled trails is a level 2 evidence. Many researchers consider a systematic review of the research regarding a particular clinical question as one of the strongest forms of evidence from evidence based nursing. According to Silvan, Schreml & Doldere (2013), guidelines present a comprehensive review of the assessment, diagnosis, management and prevention of a medical problem from a nurse’s prospective in a specific country or healthcare context, based on the best evidence available up to present. Guidelines provide information to assist decision making. In New Zealand, several bodies and organizations that deal with wound management operate under the guidelines provided by the Ministry of Health and other regulatory bodies.

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The studies that are used in the analysis of maggot therapy in New Zealand are accessed through the DermNet NZ, a website that provides resources and information on skin care and care of wounds. Insightful analysis of maggot therapy is also found online at Archives of Dermatology, the Bio Therapeutic, Education and Research Centre and other numerous institutions that provide health information on skin care. The process of retrieving articles followed the conventional approach where search terms maggot therapy for wound healing was entered and allowed the selections of reviews, abstracts, commentaries and key words. The process resulted in 6000 records being displayed in Archives of Dermatology. For the reason that EBP in wound healing treatment requires an assessment of current literature to determine the best way of applying a theory or a model, it is imperative for the physicians to embrace it so that they can apply new developments in the practice of maggot therapy.

The current status of maggot therapy in wound healing by Thomas S, J., Wynn K, and Fowler T. (2011) and Principles and Practice of Maggot Therapy by Bio Therapeutic, Education and Research Centre (2013) provided a systematic review on the MDT and the proposed principle and practice for achieving better results in the use of maggot therapy by doctors when treating non healing wounds. This process also involved searching other databases like ScienceDirect, Elsevier, and the CINAHL with search terms being maggot therapy, New Zealand wound care guidelines among others. The duration of search was kept as current as possible to receive a clear picture of the latest literature, although historical dimension was also equally important in trying to understand the origin of maggot therapy. The entire process involves a selection of an equal number of systematic reviews, articles and critique of the finding. Five articles were selected in each of the categories. While implementing the EBP approach in maggot therapy, physicians must integrate their clinical expertise with patient values and research based evidence so that they can make clinical decisions which are real and justifiable in the provision of the best care to wound healing.

People experience different types of wounds which take varied time for healing. According to Gurtner Werner & Barrandon (2008), wounds can be classified as acute and consist of normal wounds and delayed wound healing. Each of these categories carries a different healing duration even though the healing process behind them is the same. Chronic wounds show no signs of healing after six weeks and present pathology issues to treatment using antibiotics. Such wounds are considered diabetic in nature and may take up to six months to heal. This kind of wound causes inflammation of the health tissue making it difficult to heal with the normal antibiotic medicines which are common in the hospitals. The most frequent chronic wounds are caused by ulcus cricus commonly known as leg ulcer, decubitus caused by pressure ulcers, and the diabetic foot ulcers (Sherman, Hall & Thomas, 2000).These kinds of wounds commonly occur among people at the age of 70 and present multimorbidity to patients. They also exhibit multiple etiologies in the patient thus presenting a high and heavy burden in terms of care for the wound.

On their part, Joseph, Hamori & Anastasi (2010) noted that leg ulcers are venous disease or arterial diseases that cause inflammation of the skin. They also cause infections to health tissue. Ulcers can also cause tumors on the skin when the live and healthy tissues are infected. They thus cause a continuous tissue damage which cannot be controlled by using normal antibiotics. Part of the reason is that bacteria that cause rotting of the tissue become resistant to antibiotics. In addition, antibiotics cannot penetrate to the bottom infected tissue (Rettner, 2013). According to Lincoln, Radford & Jeffcoate (2008), diabetic foot ulcers are also another form of chronic wounds which are described as being neuropathic in nature as they attack the neurones that supply the nutrients to the tissue including oxygen. They are also angiopathic and musculoskeletal diseases that cause disfunction of the tissue in the infected area thus causing it to rot.

The use of maggots for medical purposes has officially been approved in many countries. For instance, this happened in the US where the Food and Drug Administration gave its green light in 2004 (Thomas, Jones & Fowler, 2011). Though scientific researches for the use of maggots to heal wounds have been documented, the number of patients agreeing to maggot therapy especially in New Zealand is still low. For instance, a recent study that included 100 men with chronic wounds indicated that the percentage of necrotic tissue of patients who received maggot therapy was lower as compared to those who were exposed to surgery. This phenomenon was removed after a longer period of time indicating that the use of maggots for treating chronic wounds is limited by the number of days. The number of patients who felt a sensational crawling feeling characteristic of maggot therapy was about the same in both groups (Denis & Drennan, 2008).

According to Rosengren, Heal & Smith (2012), the medical science behind the use of maggots to treat wounds is that they secrete enzyme that helps in dissolving the necrotic tissue in the wound while leaving the healthy one without destruction. Through this therapy, the patient may be exposed to a number of risks. However, Rosengren, Heal & Smith (2012) observed that the existence of a gross factor indicates that the trade off for the use of maggot therapy and application of usual antibiotic is good given the time that maggots are expected to dissolve all dead tissues. Nevertheless, patients who agree to receive maggot therapy have to exercise psychological strength as the therapy can be repulsive. Maggot therapy thus requires the consultation of the physician and the patient to determine the psychological preparedness of the patient before the therapy is administered. Due to the intricacies of having to use live organisms to treat an exposed tissue, the maggots to be used also should be disinfected to ensure that they do not become the agents of more bacteria into the wound. Not all maggots are able to treat wounds, thus only specific species are used. Therefore, the physician should not use any kind of maggots while treating the wounds (Vuolo, 2009; Mann, 2013).

Recommendations

The use of maggot therapy in the management of chronic wounds is steadily coming back in the medical practice. However, the ways patients and doctors have embraced this therapeutic practice in New Zealand and many other countries are not satisfying. In fact, maggot therapy was abandoned in favor of penicillin because many people thought that using live maggots to treat wounds was unhealthy. This perception characterizes the use of maggots to treat chronic wounds despite numerous research findings that maggots clean wounds better than antibiotics. Owing to the above challenges and the fact that wound management continues to be a problem to patients and doctors, it is recommended that the therapeutic approach of using maggots for wound healing should emphasize individual management as well as discovery of causal and symptomatic appearance of chronic wounds.

This should be done in the initial stages of wound development. It will help avoid progression into a state in which only maggots can be used to clean the wounds. It is also recommended that the phase specific nature of wounds should inform the recommendation for use of maggot therapy to heal the wounds. Wounds that can be healed using antibiotics should not be treated by maggots. Maggot therapy should thus be the last resort when physicians have discovered that the wound cannot be treated by antibiotics (Chowdhury & Prasad, 2013).

The use of maggots to heal wounds is well documented in the literature. However, there is missing information about the effects that more maggots can have on the wound. The standard practice guidelines in New Zealand and in other countries of the world recommend a certain number of maggots to be introduced in the wound. However, there is no information on just how more maggots could affect the process of healing. It is thus recommended that future research should delve into the effects that maggot therapy can have on the wound healing process when more maggots are used as opposed to the current standard practice. There is also an area of pain management in using maggot therapy as a process of healing wounds. Thus, researchers should explore the effect of pain on the overall healing process and if different medical prescriptions should be used alongside maggot therapy (Dealey, 2009).

It is further recommended that management of chronic wounds need to embrace the combined treatment so that the rate of healing is accelerated and the patient does not become resistant to antibiotics as well as needing to be exposed to maggot therapy. This calls for an interdisciplinary approach in the treatment of chronic wounds in patients as well as use of inter-professional understanding of various causes of chronic wounds. Maggot therapy presents a challenge to many patients as most of them loathe the feeling of maggots under their skin. Thus using an inter-professional approach will ensure that many patients accept and embrace the use of maggot therapy to treat chronic wounds. Education and awareness of both patient and physicians will also help in management of wound using maggot therapy (Jorge, 2012).

Conclusion

Use of maggot therapy in wound healing is not a recent practice in the medical history of treating chronic wounds. The introduction of penicillin temporarily stopped the use of maggot therapy to heal the wounds. However, with the emergence of antibiotic resistance bacteria, maggot therapy is finding its way back in the modern clinical practices. As a result, a revived interest in the use of maggot therapy is taking shape in the country especially in the wake of high morbidity of chronic wounds among the old and bedridden patients. In New Zealand, the Government through the Ministry of Health and other agencies has set up the guidelines to regulate the use of maggot therapy in treating chronic wounds including pressure and diabetic ulcers. The need to conduct more research on the effects of more maggots on the process of wound healing may provide an answer to the discomfort and unwillingness that many patients show when it comes to using maggot therapy to treat chronic wounds. In most cases, the cost of management of a chronic wound may be higher than is manageable by a patient but they still refuse to consent to maggot therapy. Still, with sufficient information, maggot therapy will be the clinical practice of choice when it comes to caring and managing chronic wounds.

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