Maggot therapy for difficult wounds

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I could possibly be in the last couple of years of my life without those maggots. had I not had the maggots put on, then I might not be here today. Melanie is a maggot super fan after watching these larvae eat the decaying flesh from her foot.

Are you a fan? I don't know if I am yet. It sounds quite yucky, quite icky, but we're gonna get quite up close and personal by the end of today, because we're gonna chat to Melanie in a lot more detail in a bit. We're going to meet scientists that are trying to unlock the powers of these maggots.

Because there's a real need here because of the rise of antibiotic resistant infections, those that are getting harder to treat, those super bugs are needing other forms of therapy, which includes maggots,

But first what we're going to do is see whether maggots are made, how they're produced, how they're made safe as a medicine. So I've come to a rather innocuous looking warehouse in Bridgend in South Wales. This is a maggot farm. Hello, my name's Micah Flores. I'm an R and D Research Project Manager here at Biomond in South Wales. So right now we're standing outside of our our fly room, so it's a temperature controlled room. Keep it at twenty seven degrees, give them

Twelve hours of light, twelve hours of dark, and they think it's summer all year long. We can consistently then control how often they're going through their generations and their life cycles. On a thoroughly miserable day in South Wales. I'm actually a little bit jealous. So yeah, we'll go in there in a bit and you'll get to feel how warm it is.

Obviously Michael, there's lots of different types of flies. Which ones do you choose to use for this? So they're the same ones that when I went on holiday a couple of years ago and came back to a bin that was crawling in maggots and flies buzzing everywhere'cause I hadn't taken the bins out before I went and it was a scene.

Uh, I think that's everyone's summertime problems for sure. So it is a specific fly. There's actually probably over a hundred and fifty thousand fly species and we use a single one. So it's called Lucilla sericata. It's a common green blowfly.

And it is one that you would see out in the normal environment. They will come to especially compost or your your food waste, but we also see them in forensic cases as well, so they come to decomposing things. But the ones we keep in here are are pretty clean and it's a closed colony. so we don't introduce any wildflies to this colony. So it's been closed since about two thousand and seven or eight or so. And we'll take some of those eggs, disinfect them, and we'll talk about that in a bit.

Can we go see how that happens? Yes. Let's go see some maggots. All right. So James now we're inside of the fly room. You can feel the temperatures change drastically. Yes. So um you know, we've got four weeks worth of fly cages and so the older ones are gonna smell a little bit differently just'cause they they've had their protein. They're gonna excrete things and and poop all over the cage. It almost sounds like it's raining. Yeah, that's just fly wings.

Yeah, so you can tap on a cage and you can sort of agitate. So yeah, very active, happy, healthy, ready to lay some eggs when we need it. There are boxes and boxes and boxes of them. Yes. That's the one. Twenty four thousand flies in this room, separated into four different weeks of age. Week three and four, ready to lay eggs for us, and then week one and two, just hatching, so they've got water, they've got sugar, and a lovely pair of ladies' tights at the top.

I I had noticed that sure there's a reason? Yes. We used to have complex cages and when we acquired our German business, this is how they did it plastic box, ladies' tights on top. Yeah. Breathable lid allows air exchange and the feet actually act as armcuffs to put your hands in there and add the protein and collect eggs. And then you just tie it in a nice little knot at the top and they can't escape. Rydyn ni'n mynd i'n mynd i'n mynd i'n mynd i'n mynd i'n mynd i'n mynd i'n mynd i'n mynd i chi?

It's one of the questions we ask our operators when we do hire them, how squeamish are you? I mean I've I've been working with flies for about sixteen years now, so This is nothing. It comes pretty quickly. Uh you either have it or you don't. You you find out pretty quick.

Hi James, my name is uh Professor Yamni Nigum and I'm at Swansa University. I'm an entomologist by training, so I spent um most of my life looking at insects and before I was into maggots I was looking at insects that spread tropical diseases and it wasn't until they asked me to teach a wound module for nurses I came across something in nineteen ninety eight called larval therapy. They had of course been, you know, used previously

centuries ago and also in America, in the USA and Canada. But with the advent of antibiotics in in in the forties, they w fell out of use. Well g l let's go back through that long history, kind of like what was our first known use of maggot therapy? How far back does it go?

the the Aborigines of New South Wales and the Central American Indians, the Mayan Indians, used to soak pieces of cloth in in ox blood and hang it up to the sun and that of course that would attra attract Lucilla Serracato, a medicinal maggot, who would lay eggs and as soon as those eggs had hatched,

into tiny little larvae, that would be used as a primitive dressing. Indeed it's in the Bible. There is in the book of Job there is a a mention of the positive association between maggots and wounds. But if you're thinking about more modern times, I guess we have the field surgeons of the wars. So in the Napoleonic War we had um Napoleon's field surgeon, Baron Dominic Larry, who was one of the first to write reports.

that his s soldiers had wounds that were infested with maggots, but the wounds were healing, there was no infection, no fever, so he was thrilled with that. It's a weird contradiction, isn't it? Because today, like if you just ask most people and you show them a picture of a wound without maggots and one with which is the one that's got the biggest problem, you know, your instinct would be uh the one that's infested with maggots is is not a healthy one.

No, absolutely right. And of course all over the world we use clinically controlled species. Naturally infested wounds could be any mangot. You can only use a non invasive species such as the green bottle, which does not eat healthy tissue and will just Clean, debried, necrotic tissue. So just want to say what is deprivement? Debriment is from the French word de bride, which simply means to get rid of. So when you've got a chronic wound there's so much dead tissue

and nothing will progress to heal if you've got all this blocking the wound bed. So debridment is the act of getting rid of that dead tissue. I always find the history of medicine fascinating because you you've got an idea here which traces its itself back to like ancient tribes. What killed it offers an idea because it had to be resurrected relatively recently. So kind of like where did it go?

So William Baer was a surgeon, orthopedic surgeon in America and he was also serving in World War One and he again noted, exactly as Dominic Larry had noticed, that the soldiers who had wounds were actually healing w through maggots. So when he got back after the war to his hospitals, he started to rear clinical grade maggots for treatment for his patients who had horrible wounds that were festering and not healing. And it became a remarkable success story in the nineteen thirties.

I think over three hundred hospitals were using it and it was excellent, it was really working. And then of course our most wonderful scientist ever, I think, Alexander Fleming, found this mould that was producing a juice that was killing bacteria that he'd left in his lab. It was known as mould juice.

and then it became industrially mass produced as penicillin. So who would want to put maggots in a wound when you could pop a little pill It's kind of like a beautiful story then because the reason why it's coming back is because antibiotics are starting to fail. Absolutely.

to the ancient therapy o of maggots. It became um available on the NHS in two thousand and four and, you know, worldwide approval uh in the early two thousands. Whether it's the usage is as high as it could be, that's all down to other factors. Thank you.

So um here at the maggot farm I'm being decked out in a face mask gown gloves and little blue boots and I'm off to collect some eggs from the fly room So Gemma, our production manager is. All right. It's pulling the containers out, so inside here there's a little sieve and there's protein at the bottom, so the flies think they're laying their eggs on the protein. She pulls out the sieve. Show me an egg. I don't even know if I'm looking at the right thing. So they're laid in clumps.

Oh w sorry, that's all eggs. I thought that was just like a ball of cotton wool or something. How many eggs are there in there? That looks like Is there's probably ten thousand or so yeah. Each group of cage will lay about thirty five grams of eggs, which is about thirty five million larvae. If we let'em all hatch up. Yeah. Thank you. Sorry, I sounded way too keen. Субтитры сделал DimaTorzok Is my arm going in there? Yes. Ha ha ha. You've already said yes. You are.

Yeah. Okay, so hand goes in the ladies' tie. Продолжение следует... The no flies. Yeah, come out. There's an art to it. She made it look simple. I'm right. I'm left. Ja. Yeah, if you sort of tilt them'cause they can't come out past the palm of your hand. Another little shake. That's fine. That looks good. Exactly. Sorry. Bye. Thank you. Right. We've had to get changed, yeah.

So we are in portion of the clean room where we start the egg separation process. So all those eggs that you were just collecting, getting the flood. those clumps, we want to separate those into individual eggs, so we want to make sure that we can disinfect. the whole outer layer of that egg. So what Bev is doing here is she's adding a solution that's actually gonna break up the little bits of glue that are holding those eggs into clumps. She places it on a rotator and now it's just gonna spin.

put in it. That's it? Yep. It's been auto claimed so that it is sterile. And we're spinning around. Yes? It doesn't quite separate all of the clumps, and so the next step after this is to put them through a series of sieves. And why do you need them to be just individual? If they're clumped together, even if it's just two stuck together in between those two, could be some bacteria. Since we're gonna use this on a patient.

Skip all the way round to the final step then if we get let's go have a look at some magnets. Have a look. Kim is actually wearing these irradiated garments. So these have been gamma-irradiated to make sure they're sterile. The larvae that are on plates will actually be taken into that cabinet along the back and placed into a tube. They also then dose the maggots out.

get a biobag fifty all the way to a biobag four hundred. What that means is a minimum of fifty larvae inside of there. A biobag four hundred has a minimum of four hundred and it's a ten by ten centimeters square. That's huge. Yes. So it it's a big bag and it gives them enough

room'cause they're gonna grow quite big and then we heat seal the end and so the maggots are left within the bag. And that means that you don't have free roaming maggots on your wounds. Um they're sealed within this nice little almost tea bag like idea. Again, don't come to mind for breakfast. Um You're really putting me off. And you can just set that in a wound then and it can set there for three to four days for the treatment time. You've got some samples. Have a good day.

So Start with the size the maggots. Start off. Come off of the Yes. Four to seven millimeters is what we're shooting. Small. Yes. So they're about one day old and they've got enough reserves that they can ship for that forty eight hour time point until they need to be on to a patient. Oh yeah, they they will be hungry when they get to The to the patient and they're they're ready to do their job. So they're just a tiny little white. Yeah. With like a little black head? I assume that is the head.

Yeah, so that's the the mouth hooks um that they use to kinda help scrape and move along their surface. What do they eat? So they eat necrotic tissue. They like it as it's starting to go bad and go off because their enzymes that they secrete can actually break down that necrotic environment and they slurp that up. The way that they feed is it's called extracorporeal digestion. Yeah. So that's a much better way of saying they barf up a load of digestive juices than suck it on.

Yes. It's I guess spitting out our stomach acid or something onto something, letting it kinda liquefy and then trying to slurp it back up. They don't have a need to break down healthy tissue. Yeah, once they've done loads of extracorporeal digestion, how big do they get? Yes. So then they're gonna get to about fourteen to fifteen millimeters. See these things almost look cute. Those things do not.

Can be quite a shock if you've never seen it before when you open that wound and you see them start to grow and so after four days they're done feeding. You're not gonna get anything more out of them and so we say take them off of the wound. They're still in the t the tea.

They're in the tea bag at this point. Yes, exactly. Yeah, so it's easy to remove them. So they've done they've served their purpose, they've done their job. There is no happy ending. The happy ending is for the patient who has now a wound that is improved and is probably likely gonna go on towards healing. Well that was quite disgusting, wasn't it? Just be thankful if you're feeling a bit at home that you're not actually having to be there or see any of the pictures. Sometimes

Audio is a blessing, isn't it? Right then, so we've got these medical larvae. What happens next is they get ordered in on prescription, you can't just go out and buy them. So the cost of the NHS each time is a couple of hundred quid depending on how many larvae they need.

So now we're going to go to the Morriston Hospital in Swansea to see how they're actually used. Hi, Melly, how are you today? I'm fine, Rob. Any concerns with your feet since I've seen you last? The one I had a recent surgery on is still swelling a little bit and I'm getting quite a bit of neuropathy pain. So Melanie, who we heard from right at the beginning, is having one of her feet examined because of her type one diabetes.

High blood sugar levels can lead to a loss of sensation in the feet, so injuries are more common, and it can also damage blood vessels so that wounds take longer to heal. My name is Ros Thomas. I'm one of the acute podiatrists here in the Diabetes Centre at Morstan Hospital in Swansea. We mainly deal with patients who've got severe wounds and they could be living with diabetes or just have vascular problems or just had an injury to their foot that's not healing.

Yeah. How many times have you used maggot therapy? Do you remember your first time? Like when you first got into it. 26 ydym yn ôl i'r wad i'r wad i'w wneud y patient gyda un o'r doktorau, ac mae'r ffarmacist yn ôl, ac mae'r ffarmacist yn ôl, mae'r ffarmacist yn ôl, mae'r ffarmacist yn ôl, mae'r ffarmacist yn ôl, mae'r ffarmacist yn ôl,

And I froze to the ground'cause I remember my brother fishing and seeing a pot of maggots. I thought, Oh, they're gonna have to get somebody else to put these on. And thought, Oh, it's not so bad. They're tiny little things. But when they came off they were nearly a centimetre and they were just like my brother's jar of maggots when he went fishing. Tell me the story.

I had an infection in my foot. I'm diabetic. I had my little toe and the next toe off and then like a quarter of my foot removed and that was all very shocking and very quick and never thought it would happen to me. I had a choice that um I either have the maggots put on my wound or I could risk and I'd been on Dr Google and I knew the risks of losing my leg at that point and But that's the choice you were facing. That was the Yeah. Rolling the d rolling the dice.

A lot longer healing process. They would have had to have waited for that necrotic skin to naturally fall off. I mean, there would be other treatments not as effective as the maggots. Can you remember the moment when someone first suggested it? I was quite depressed. I remember I was crying anyway. Do you know what I mean? Thanks for a lot. Rydyn ni'n fwyaf. Rydyn ni'n fwyaf. Rydyn ni'n fwyaf. Rydyn ni'n fwyaf. Rydyn ni'n fwyaf.

Rydyn ni'n gweithio. Rydyn ni'n gweithio, ond mae hynny'n gweithio, ond rydyn ni'n gweithio, ond rydyn ni'n gweithio. Rydyn ni'n gweithio, ond rydyn ni'n gweithio. But it was mentioned and I did know about Margot, you know, I'd read about uh people having car accidents and being in the

hidden for a week out in the middle of nowhere and that maggots had saved their foot or anyway j uh uh Ross suggested it to the surgeon at the time and he agreed. Normally you would have had to have gone away and oedden nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw.

And very quickly within, I don't know, half an hour of being there, the decision being made, I had this giant teabag on my foot with all these little tiny r wriggly things on the wound that you couldn't even see it. Did you get a good look before they went?

Yeah, they were they weren't gruesome like that. I love to have a look at all that sort of stuff. But i they they were minute. They were like uh well you went this morning and saw that the thing th they were they were almost like strands of cotton. Rydyn ni'n ei wneud yn ei wneud, ac roedd yn ei wneud yn ei wneud. Rydyn ni'n ei wneud. Rydyn ni'n ei wneud. Rydyn ni'n ei wneud. Rydyn ni'n ei wneud. Well he's used to be bringing stray animals home, but not a leg full of maggots.

I couldn't feel them really, but it's like with somebody who mentions head lights, you know you can't tell scratching. I think I was imagining that I could feel them. And they smelt more than anything. That was you know What was the smell? Oh, like the bottom of a dustbin. The first few days is fine, but you have to let them breathe, so you can't sort of cover it up with a bag or change the dressings or anything. You have to leave everything alone and just as well.

Mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod, mae'n gwybod.

Melanie mentioned about the smell. They do give off a smell of ammonia when they're cleaning up the wounds. Obviously, they're living creatures, so they're going to... ac mae'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw Why aren't they used more widely then? If they're so good?

I don't know whether it's education for other healthcare professionals, especially out in the community, or whether GPs look at the cost of one unit of them and think, oh, that's too expensive. Mae llawer o'r dyrwyddiadau neu'r dyrwyddiadau'r dyrwyddiadau o'r dyrwyddiadau o'r dyrwyddiadau. Mae llawer o'r dyrwyddiadau o'r dyrwyddiadau o'r dyrwyddiadau. But is the evidence there that they are really good and really effective?

Yes, there is. I mean, there's lots of clinical studies and case studies to show how well they work and how efficient they are. And And they say... Really? What? Mae'n ymwneud â nhw'n ei ddweud, ac mae'n ymwneud â nhw'n ei ddweud. Mae'n ymwneud â nhw'n ei ddweud ymwneud â nhw'n ei ddweud â nhw'n ei ddweud â nhw'n ei ddweud â nhw. But most of them will they're just terrified of losing their legs, they will agree to anything at that point.

I have a real healthy attitude towards them now. I salute them when I see them at the bottom of the recycling bin. They are the most amazing thing and I would recommend. ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw'n ymwneud â nhw. Fly swater and the fly spray, they've all been No, well I never had them anyway. Everything deserves to live and I and that was another problem I had with having the maggots was that I was a vegetarian

you know, I didn't like any thought of anything dying, f even if it was saving my foot, possibly my life. But I went through it, I had it and um you're only shortening their life I think by a few days anyway, and they and they ate well while they were there. They know I fed them well. Did you see them when they came off? Yes, and I've got pictures as well. I'll be quite there. They were like the size of cr cooked rice. Oh, I really, really hope you're not eating any rice right now. If you are

I'm sorry. Not that maggots would put Professor Yamley Nigam off her food here at Swansea University. They're her specialty, and oh can you tell when you go around her office? Maggot pictures on the wall, themed mugs, even maggot cuddly toys. But what I wanted to find out from her was why aren't they being used more widely? Are we just a bit too squeamish or are there other problems here? Are they just too much hassle to use?

Yeah, you know, I think there are many, many factors involved. One of them, as as we've discovered in our research, is called the hassle factor. You can't just pick off a dressing of that's in your shelf, a honey or silver or iodine, all these dressings are available, but maggots have to be ordered in. Yeah, be really suspicious if your doctor goes, Yeah, I've just got some maggots on the shelf. Yeah, don't don't trust that doctor, right?

Exactly, exactly. So then there's a factor of you have to go through GP in the in the community to order it. or in the hospital you have to go through pharmacy, it's whether they've got it on their system. Although the company are working to try and make that a lot easier. And of course there is an inherent and cultural

dislike of things like maggots, creepy crawlies. And it is one of those things that you have to explain very clearly to the patient the benefits of and the wisdom of using maggots as opposed to something else. And y and y what we usually find is that most nurses who uh lead wound care in the UK only prescribe maggots as a last resort. Wounds can stay stagnant for years. They've tried everything else that they possibly can.

And that's one of the we I was in a uh a meeting yesterday with some students from Cardiff University and we one of the n uh podiatrists actually said that I always use it at the end and it works amazingly. And I thought kind of well, why why don't you Yeah, and and it's not just the cost of everything that you're using before, it's it's the time for the for the podiatry, for nursing, for and and for the poor patient.

To have this wound that isn't healing for like eighteen months and then you put maggots on for four days and you see the turnaround is absolutely amazing. She's thinking, yeah, you know, I probably should probably look at them as a first resort. But it's for some reason it's just the last thing people look at.

Have there been enough of the rigorous trials?'Cause like if you were to bring a new drug to market it gets trialed extensively before you know it it gets rolled out. Do we have those big trials that go, Yeah, maggots definitely do help wound heat? We have a couple. So'cause it's relatively new and doing a massive trial comparing maggots with an alternative dressing, for example, is a massive feat because you need

So many patients that have very similar wounds. You have your control group that won't be treated on maggots, and you have the group that will. So it was the University of York that carried out the most comprehensive study, Venus two, I think it was called, on leg ulcers, and they absolutely found that for debriidment, they found that it was amazing and it worked uh better than all the alternatives that they'd looked at.

So that was the most rigorous trial. But there have been others that have looked at infection, disinfection of a wound, and others still that have looked at wound healing. And I would say for the latter two, there isn't your class one RCTs which are considered The gold standard. Yeah, I think we we need more of those.

Where do you think this field is going?'Cause'cause we talked about antibiotics earlier and and mould morphed into a purified drug that could be manufactured and then prescribed to somebody. Do maggots need to go through the same process where actually y y you're going to look at what the maggots are doing and harvesting some of those enzymes that break down decaying tissue or some of those antimicrobials and that's what we're going to use in the future, or is the future still maggoty?

First of all, I'm a huge advocate of the real living thing because it is producing not just enzymes for deprived, it's producing a range of antimicrobial factors. And that's one of the things that at Swans University we were studying for the last decade plus.

We've isolated a tiny little antimicrobial factor which we've trademarked as seratocin. It's a tiny little molecule and it kills MRSA, it kills C. diff, even resistant bacteria. We've also found an antifungal factor. And in fact a German group has recently shown that Um Lucilla Sericata, this green bottle fly, possesses the genes for forty seven different antimicrobial peptides, which it will secrete once it's on the wound.

So isolating solitary factors, yeah, might work, but then we might find that yes, you've got the magasratin molecule out, you've turned it into a brilliant cream or lotion or even tablet, but that's it, and you're not giving them the benefit. off the other the cocktail. Absolutely. And we also know that's some of the research that we've done here, is that maggots contain wound healing abilities as well. Once you've deprived a wound and got rid of all the dead tissue

and then you've disinfected a wound. That wound can only heal when good cells that we call fibroblasts enter the wound and start to make the new collagen, the new elastin. And we've found that maggots entice that. All the research is showing that fibroblast migration occurs better if you've had maggots present on your wound. You understand why they're eating your dead flesh, because that's it's an entirely selfish act. But why are they secreting

antibiotics basically into that area to clear out bacteria and why are they promoting wound healing? Surely they'd want the wound to stay open so they could keep munching away, right? Absolutely, yeah, you've got you've got such a good point here. First of all, if we look at the natural environment, the female fly will lay her eggs where there is something for the little larvae to feed on. She will lay in dead carpets.

Now we also know that the very first decomposers of a dead rat or a pigeon or a sheep or whatever are going to be bacteria and fungi. Because they are primary decomposers. So they will be starting that process. The little larvae will emerge and suddenly have a horde of bacteria around it and have fungi around it. So they're the competition.

So they're the competition. So for their own survival, maggots have evolved awesome antimicrobial molecules. So that's why in a wound they'll be secreting those. They will. secrete I think times sixfold if they're put in i with an infection.

Well you've converted me until the next time I open my kitchen bin and there's just a swarm of them escaping. I got you, but that might not be Lucilla Sericata, that might be another horrible species of housefly or blue bottle. Well then, what do you think? Are you converted or is that just something that's a little bit too yucky to go anywhere near your body? Let me know. Twitter at James T Gallagher or email insidehealth at BBC.

Dot co dot uk. And remember, you've still got time to send in any questions you have on back pain for a special we're doing later in the series. But thank you for listening to the Inside Health Podcast with me, James Gallagher. The producer was Paula McGraw and the studio manager was Tim Heffer. See you next time. Ingo, det är en bensinstation Sväng in, tanka. Alltid till ett hårt pris. Huntor and Grand Slip! Ja, det var en stor slam. Men ICAMAX är störst.

Just nu, röda vindruvår i ask 500 gram för 25 kronor, ika maxi störst på låpriser.