Myiasis: Nursing Intervention

Myiasis: Nursing InterventionMyiasis: Nursing InterventionBy: Bridgette C. Williams, BSN, RNBy: Bridgette C. Williams, BSN, RN

SUNY Institute of TechnologySUNY Institute of Technology

Lesson Plan: Myiasis• Topic: Myiasis (maggot infestation for nurse clinicians and educators)• Prerequisites: Undergraduate nursing degree • Objective: Differentiate types of myiasis in context of the nursing process• Rationale: Myiasis is an occurrence in the health care setting• Part I: Classification—types of myiasis infestation• Part II: Fly Life Cycle—development from egg to fly• Part III: Signs & Symptoms—signs of maggot infestation• Part IV: Nursing Interventions—protocol for maggot removal• Part V: Conclusion

December 2011 B. Williams, BSN, RN, MAMS 2

Presentation Objectives• At the end of this presentation learners will be able to:

– Define myiasis.– Identify one myiasis classification.– Describe at least 2 signs of infestation.– Explain at least 2 stages of the fly reproductive life cycle.– Differentiate at least 2 risk factors.– Apply at least 2 nursing interventions to care plan for myiasis.


PART IPART IClassificationClassification

Definition• Myiasis (sounds like my-eye-uh-sis)

– is the infestation of maggots in or on the body• Nosocomial myiasis

– is the occurrence of maggot infestation in the hospital setting• Myiasis can be classified according to type or clinical presentation

• (Robbins & Khachemoune, 2010; Tucker & Goulard, 2008; Merriam-Webster’s collegiate dictionary, 1995).


Myiasis ClassificationClassification by type

•Obligate: fly eggs on any host surface•Facultative: fly eggs on opportunistic areas•Accidental: fly larvae feed on host not of usual source

Classification by clinical presentation•Cutaneous•Orifices•Intestinal•Wound

•(Trombetta, Oliva, Galache, Bava, & Troncoso, 2009; Werminghaus, Hoffman, Mehlhorn, & Bas, 2008; Robbins & Khachemoune, 2010; .Das, Madan, & Gautam, 2010)


Fly Families• Oestridae family. This is subdivided into 3 subfamilies:

– Oestridae (sounds like es-trid-ee)– Calliphoridae (sounds like cal-lif-or-id-ee)– Sarcophagidae (sounds like sar-cof-aj-id-ee)

Specie Examples• Dermatobia hominis—bot fly–Oestridae family

• Cochliomyia hominivorax—blow fly—Calliphoridae family

• Wohlfahrtia vigil—flesh fly—Sarcophagidae family

• (Robbins & Khachemoune, 2010).


Quiz Question 1• True of False: The common house fly (Musca domestica) does not cause

myiasis.


Quiz Question 1 Answer• Answer: False. The common house fly can

cause myiasis. It is facultative

• (“Facultative myiasis-producing flies”, 2011).


Image Source:

http://www.naturephoto-cz.eu/musca-domestica-picture-14134.html

Musca domestica

Cutaneous Myiasis• Cutaneous myiasis is subdivided into 3 types by clinical manifestation:

– Furuncular: Larvae presents as a boil lesion– Migratory: also known as creeping. Larvae moves under skin layers– Wound: also known as traumatic. Larvae presents in wound bed



Furuncular Myiasis Epidemiology

• Dermatobia hominis, human bot fly• Obligate parasite• Found in Mexico and South America• Often affects dogs, cats or cattle• Eggs on surfaces & vectors• Site specific• Invasive; it burrows under the skin to cause a boil

• (Trombetta, et al., 2009; Robbins & Khachemoune, 2010; Gingrich, Spickler, & Davis, 2004).


Image Source: http://www.greatapeproject.org/en-US/curiosidade.info/Show/

1942,have-you-ever-eaten-a-buge

Dermatobia hominis

Migratory Myiasis Epidemiology

• Gasterophilus spp., horse bot fly• Most common parasite to horses• Obligate parasite• Eggs on the hairs of horses• Distinct serpentine pattern visible under skin• Infestation is by contact with an infected horse



Image Source: http://www.slow-life.co.uk/2010/02/03/the-evil-bee/

Gasterophilus spp.

Wound Myiasis Epidemiology• Cochliomyia hominivorax, blow fly• Obligate parasite• Distributed in warm areas of the Americas • Infestation frequently associated with animals• Female fly lays hundreds of eggs• Larvae of this specie will feed on living tissue

(usually larvae feed on dead tissue) • Distinct odor in wound• Death can result if not treated

• (Trombetta et al., 2009; Robbins & Khachemoune, 2010; Gingrich, Spickler, & Davis, 2004)


Image Source: http://www.icb.usp.br/~marcelcp/Cochliomyia.htm

Cochliomyia hominivorax

Quiz Question 2• True or False: Myiasis is only associated with open areas.


Quiz Question 2 Answer• False. Myiasis can occur on intact skin.

• (Robbins & Khachemoune, 2010)


Image Source: http://www.icb.usp.br/~marcelcp/Dermatobia.htm

Dermatobia hominis

PART IIPART IILife CycleLife Cycle

Life Cycle• Fly lay eggs on an area

1. Eggs are deposited on host2. Eggs hatch usually within 24 hours3. Larvae emerge from eggs.

• instar (usually up to 3)• spiracle

4. Mature larvae leave host to pupa.5. Within pupa, metamorphosis into

reproductive fly

• (Sherman, Roselle, Bills, Danko, & Eldridge, 2005).


Image Adapted From: Sherman, R.A., Roselle, G., Bills, C., Danko, L.H., & Eldridge, N. (2005).

Healthcare-associated myiasis: Prevention and intervention. Infection Control And Hospital Epidemiology, 26(10), 828-832.

Image Adapted From: Nazni, et al. (2011). Nosocomial nasal myiasis in an intensive care unit.

Malaysian Journal of Pathology, 33(1), 53-56.

Life cycle

Spiracle

PART IIIPART IIISigns & SymptomsSigns & Symptoms

Signs & Symptoms of Infestation

• Redness, pain, swelling• Intense itching (pruritus)• Sensation of movement under skin• Serous or serosanguinous discharge at site• Malodor if affected area is wound bed• *Thread like structure removed

• (Sharma, Pai, & Pai, 2008).

• *Definitive diagnosis of myiasis is by nurse practitioner or physician if identification of larva removed from area.


Image Source: http://www.langetextbooks.com/_levinson/gallery.php?id=m-n

Quiz Question 3• Describe 2 signs of infestation.


Quiz Question 3 Answer• Redness (locale)• Pain (locale)• Itching (locale)• Swelling (locale)• Sensation of movement under skin• Discharge at site• Malodor (if in wound bed)


Case Study 1• A 75-year old woman with venous hypertension and diabetes presented

to the emergency room for an ulcer on the right leg. Necrotic tissue and tunneling were present in the wound bed. “Worms” were observed by the nurse assistant. What is the possible clinical presentation?


Case Study 1 Answer• Answer: Wound myiasis

• (Victoria, Trujillo, & Barreto, 1999).


Case Study• A 25 year old man from a rural setting presented to an outpatient clinic

complaining of passing worms in the stool for the past month. He had no complaints of blood in the stool. Blood pressure was within range. Stool sample collected and lab technician reported 4 active “worms” were microscopically identified. What is the possible clinical presentation?


Case Study 2 Answer• Accidental myiasis

• (Das et al., 2010).


PART IVPART IVNursing InterventionsNursing Interventions

Risk Factors1. Patient

– Limited mobile/immobile; poor hygiene of skin and orifices– Open wounds not covered– Immune-compromised– Cognitively impaired

2. Environment– Warm climate (e.g. tropical or summer weather season)– Food containers left uncovered in room– Overflowing garbage bins in room

• (Sherman et al., 2005).


Nursing Intervention for Myiasis

1. Notify the patient2. Calm the patient and/or staff3. Notify the nurse supervisor or nurse manager4. Locate the medical center policy and protocol to control myiasis5a. Using standard precautions, remove larvae (NP or MD)

• Brush the larvae out. DO NOT SMOOSH or SMASH. Put intact larvae aside.

5b. If entire larvae not visible [in skin], apply petroleum jelly

•(Department of Veteran Affairs, Policy Memorandum 512-11, 2009; Sherman et al., 2005; Victoria et al., 1999).


Nursing Interventions...continued

6. Larvae (all) in specimen cup. Add 70% isopropyl alcohol in cup. • Seal cup. Label: write patient’s name, date, time, name of clinician who collected specimen and type of solution. • Send to lab IMMEDIATELY (within 24 hours).

7. Wipe infected area; use sterile saline or hydrogen peroxide or Dakin’s solution [0.125% sodium hypochlorite].

8. Soak infected area using hydrogen peroxide and water mixture (1:3) Soak for approx. 20 minutes.

• (Department of Veteran Affairs, Policy Memorandum 512-11, 2009; Sherman et al., 2005; Victoria et al., 1999).


Nursing Interventions...continued

9. Dispose of used dressings in proper receptacle. Apply new dressings

10. Document what was done. • Often, broad-spectrum antibiotic (i.e. Ivermectin) is prescribed

•(Department of Veteran Affairs, Policy Memorandum 512-11, 2009; Sherman et al., 2005; Victoria et al., 1999).


Critical Reasoning Exercise• An 83 year old patient with diabetic foot ulcer is diagnosed with

Alzheimer’s and PVD is in your care. You are the charge nurse of the 70 bed nursing home facility and the only RN on shift. The doctor is on call. The nurse assistant frantically calls for your assistance. The nurse assistant tells you she was attempting to adjust the sheets in the in the bed and observed the dressing fell off and “white worms” were seen crawling in the wound bed. As the charge nurse, apply 2 nursing interventions for possible myiasis infestation.


Critical Reasoning Exercise Ans.

• Standard precautions and check on the patient to ensure safety.• Assess vital signs, pain, wound bed. Offer pain med. • Notify the nurse manager/supervisor. Notify the doctor on call. • Access myiasis policy/protocol/procedure.• Perform myiasis removal. Be sure to preserve the larva in 70% Isopropyl

alcohol labeled and sealed in a specimen cup. Clean the wound bed as stated in protocol.

• Contact lab; notify technician of pending arrival. Send specimen to lab immediately.

• Document what was done.• Look for new orders.


Myiasis Prevention• Cover all wounds• Change wound dressings as ordered and when visibly soiled• Keep open orifices clean, especially if patient has an artificial airway• Establish a turning or repositioning schedule for limited mobile patients• Thorough skin assessment at least 1 time per week• Do not leave open food containers in room• Keep garbage receptacles covered with a lid

• (Sherman et al., 2005)


PART VPART VConclusionConclusion

Conclusion• Nosocomial myiasis is maggot infestation which occurs in a hospital.• Common signs/symptoms include redness, pain, itching.• Risk factors include open wound beds with or without necrotic tissue,

bed-ridden patient and unkempt environment.• Nosocomial myiasis is preventable.

Additional Information:The Center for Food Security & Public Health, Iowa State University:

http://cfsph.iastate.edu/DiseaseInfo/disease.php?name=screwworm-myiasis&lang=en


Reflection• Constructing science information in the format of a slide presentation is

challenging. Many details must be abbreviated on slides.• First experience constructing presentation with quiz questions, case

studies.• First experience including a synthesis critical reasoning example.• First experience using online survey Zoomerang©. • First presentation using Elluminate Live! V.10©.


Evaluation• Thank you for viewing Myiasis: Nursing Intervention presentation. Below

is a link to Zoomerang© survey evaluation. Please take 10 minutes to answer questions. This survey can be completed at any time. If you would like to contact me. Please see contact information on final slide.

• http://www.zoomerang.com/Survey/WEB22E58645U4D


References• Das, A., Pandey, A., Madan, M., Asthana, A.K., & Gautam, A. (2010). Accidental intestinal myiasis caused

by genus Sarcophaga. Indian Journal of Medical Microbiology, 28(2), 176-178.

• Department of Veteran Affairs, A Maryland Health Care System: The Infection Control/Hospital Epidemiology Program (111/MD). (2008). Policy Memorandum (512-11/COS IC-015).

Baltimore, MD: Author. • Facultative myiasis-producing flies. (2011). The Merck Veterinary Manual. Retrieved from:

http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/71719.htm • Gingrich, E., Spickler, A.R., & Davis, R. (2004). Screwworm myiasis [PowerPoint presentation]. The Center

for Food Security & Public Health Iowa State University. Retrieved from: http://cfsph.iastate.edu/DiseaseInfo/disease.php?name=screwworm-myiasis&lang=en

• Myiasis. (1995). In Merriam-Webster’s collegiate dictionary (10th ed.). • Robbins, K., & Khachemoune, A. (2010). Cutaneous myiasis: A review of the common types of myiasis.

International Journal of Dermatology, 49, 1092-1098. • Sharma, P., Pai, H.S., & Pai, G.S. (2008). Furuncular myiasis mimicking pyoderma [Letters to Editor]. Indian

Journal of Dermatology, Venerology and Leprology, 74(6), 679-681.


References• Sherman, R.A., Roselle, G., Bills, C., Danko, L.H., Eldridge, N. (2005). Healthcare-associated myiasis:

prevention and intervention. Infectious Control and Hospital Epidemiology, 26(10), 828-832.

• Trombetta, L., Oliva, A., Galache, V., Bava, J., Troncoso, A. (2009). Cutaneous myiasis due to Cochliomyia hominovorax in a drug user. Journal of Infection in Developing Countries, 3(11), 873-876.

• Tucker, S. –M., & Goulard, S. (2008). More than just a fly on the wall: A case of nosocomial myiasis in the intensive care unit. Canadian Association of Critical Care Nurses, 31.

• Victoria, J., Trujillo, R., & Barreto, M. (1999). Myiasis: A successful treatment with topical Ivermectin. International Journal of Dermatology, 38, 142-144.

• Wa, N., Jeffery, J., Lee, H.L., Lailatul, A.M., Chew, W., Heo, C.C., Sadiyah, I., Khairul, M, -A., Heah, S.K., Mohd, H.H. (2011). Nosocomial nasal myiasis in an intensive care unit. Malaysian Journal of Pathology, 33(1), 53-56.

• Werminghaus, P., Hoffman, T.K., Lehlhorn, H., Bas, M. (2008). Aural myiasis in a patient with Alzheimer’s disease. European Archives of Otorhinolaryngology, 265(7), 851-853. doi: 10.1007/s00405-

007-0535-2


ENDENDBridgette C. Williams, BSN, RN, MAMSBridgette C. Williams, BSN, RN, MAMS

[email protected]@sunyit.edu

Myiasis: Nursing Intervention

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