Larval Debridement Therapy Linda J. Cowan, PhD, ARNP, FNP-BC, CWS Research Health Scientist North Florida/South Georgia Veterans Health System Disclosures Presenter(s) has the following interest to disclose: Research Funding Veterans Health Administration University of Florida Biomonde, Inc. Healthpoint, Inc. Celleration Medline PESG and AMSUS staff have no interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. PESG, AMSUS, and all accrediting organization do not support or endorse any product or service mentioned in this activity. Objectives Identify potential benefits of using LDT Describe UF Larval Debridement Therapy (LDT) experiments with biofilms and current VA LDT Clinical Trial Discuss appropriate clinical use of LDT Discuss common barriers to LDT use In Vivo Experiments at UF Pig skin explants sterilized, inoculated with: Pseudomonas Staphylococcus Stressed with Gentamycin Biofilm growth stimulated Mature biofilm colony confirmed on day 3 + ESM pics Larvae applied, measures of biofilm after: 24 hours 48 hours 72 hours Before Larval Debridement SA day mature biofilm culture on pig skin explant After Larval Debridement SA35556 biofilm culture 24 hours after LDT Before Larval Debridement PA01 (3 day mature biofilm culture on pig skin explant) After Larval Debridement PA01 biofilm culture 24 hours after LDT Analysis Appropriate Use of LDT Yes: Open human wounds with necrotic tissue Stalled wounds PU, VLU, DFU, non- healing surgical wounds Full thickness wounds Moist wounds Deteriorating wounds Infected wounds No: Weight bearing wounds (no squished maggots) Very dry or hard eschar over most of wound Under occlusive dressings Fistulas Exposed blood vessels Very high PT/INR In combination with certain wound products The Process Bagged Larvae Original diagram by Bytemedia General Info: Bagged Maggots Heat sealed mesh pouch Contains maggots and hydrophobic foam spacer Allows for easy examination of wound Easy to apply 4 day treatment time Typical Sizes of Bags Application SkinWound Barrier Bag larval dressing Place moistened Gauze over Bag Absorbent pad Secure with cover dressing Free-Range or Bagged Free-Range larvae * Cavities/undermining *Wherever depth or shape of wound will not allow sufficient contact of bag with wound bed Bagged larvae * Most other wound types Can bagged maggots work as effectively as loose larvae? As long as bag can contact wound bed, yes! Care of Larval Wound Apply saline moistened gauze cover dressing daily Only use non-occlusive dressings Avoid sustained direct pressure The wound does not require irrigation during LDT Maggots are a live product and need to be treated as such What to Expect with LDT There will be an increase in exudate initially The exudate can be dark red or brown There can be a distinctive odor (musty) Maggots can be used under non-occlusive compression The larvae should increase in size during usage 2015 VA Clinical Trial RCT comparing LDT with sharp debridement to remove bacterial biofilm in 140 subjects Comments of patients and providers Yuck factor? Day Day Day Day 8 -- LDT LDT remove LDT preX post X2----postX postX4 LDT Day Day Day Day Day 8 -- SD SD preX1 --- post X2----postX postX4 SD Clinician and Caregiver Instructions Clinician proficiency Checklist Caregiver instructions Before and after 1 LDT application Day 0 RCT before LDT Day 4 after 4 days LDT Removing LDT Disposal: Double bag in medical waste (red bag) Dispose as per local and facility protocols Barriers/Challenges to LDT Offloading especially in DFU is difficult Knee walkers, crutches, wheelchair, total contact casting Ordering procedures for LDT Order correct size number of larvae Must be applied within 1 day Summary LDT is an effective method to assist wound bed preparation T-I-M-E* principles in practice LDT is a potential anti-biofilm strategy When used appropriately LDT is an essential part of a targeted multiple factor approach Combination therapies: disruption or removal of biofilm (such as LDT) + antimicrobials Ongoing studies Human RCT: LDT vs. bedside sharp debridement *Schultz, G & Dowsett, C. (2012). Wound bed preparation revisited. Wounds International, 3(1). Available at: References Blake, F.A., Abromeit, N., Bubenheim, M., Li, L. & Schmelzle, R. (2007). The biosurgical wound debridement: experimental investigation of efficiency and practicability. Wound Repair Regen, 15 (5), Bryant, R. & Nix, D. (2011). Acute & Chronic Wounds: Current Management Concepts (4 th ed.). St. Louis, MO: Mosby, Inc. Cowan, L.J., Stechmiller, J.K., Phillips, P., Yang, Q. & Schultz, G.S. (2013). Chronic wounds, biofilms, and use of medicinal larvae. Ulcers, 2013, Article ID , 7 pages, Doi: /2013/ Cowan, L.J., Phillips, P., Stechmiller, J., Yang, Q., Wolcott, R. & Schultz, G. (2013) Chapter 4: Antibiofilm Strategies and Antiseptics. Antiseptics in Surgery Update 2013, edited by Christian Willy. Lindqvist Book Publishing: Berlin, Germany. Davis, S. C., Ricotti, C., Cazzaniga, A., Welsh, E., Eaglstein, W.H. & Mertz, P.M. (2008). Microscopic and physiologic evidence for biofilm-associated wound colonization in vivo. Wound Repair and Regeneration, 16(1), Dowd, S.E., Wolcott, R.D., Sun, Y., McKeehan, T., Smith, E., et al. (2008). Polymicrobial nature of chronic diabetic foot ulcer biofilm infections determined using bacterial tag encoded FLX amplicon pyrosequencing (bTEFAP). PLoS ONE 3: e3326. doi: /journal.pone Leaper, D.J., Schultz, G.S., Carville, K., Fletcher, J., Swanson, T. & Drake, R. (2012). Extending the TIME concept: what have we learned in the past 10 years?* International Wound Journal, 9 (Suppl. 2), Phillips, P.L., Wolcott, R.D., Fletcher. J. & Schultz, G.S. (2010). Biofilms made easy. Wounds International, 1(3), 1-6. Available fromSchultz, G.S., Sibbald, R.G., Falanga, V., Ayello, E.A., Dowsett, C., Harding, K., et al. (2003). Wound bed preparation: a systematic approach to wound management. Wound Repair Regen, 11, 1-28. 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