The asticothérapie indicates the intentional introduction by an expert of health of larvae (Asticot S) disinfected beforehand of a species of fly, the Lucilia sericata or green Mouche , in a wound in order to look after it. The wounds must be in soft fabrics of the human body (or of an animal).

The maggots of this fly, used since the Antiquity, have the property to consume only the necrosed fabrics (deaths) by facilitating the Cicatrisation healthy fabrics, and by stimulating the production of cicatricial tissues, while disinfecting the wounds without use of Antibiotique S.

Synonyms

The asticothérapie is called “Madentherapie” by the Germans and the Netherlanders, “Maggot Debridement Therapy” (MDT) by the english-speaking, who also speak about “larval therapy” , “larva therapy” or “larvae therapy” .

History

The use of maggots is documented by chroniclers for the treatment of wounds as of Antiquity, with the Rebirth (in Europe) and more recently. The Indians Maya and some Aborigènes of Australia used also this technique.

• Ambroise Paré uses them with the Siège of St Quentin (Picardy) in 1557, associated with a Onguent with oil of lily.

• Of the army medical officers had as observed as soldiers whose wounds were colonized by certain maggots cured better or more quickly than those whose wounds were not it. It was the case of Dominique Larrey, surgeon of the general Napoleon Bonaparte, who had noticed at the time of the Egyptian countryside in Syria, in 1829, that certain species of maggots ate only the dead fabrics of the wounds, with a positive curative effect at the casualties.

• Later, Dr. Joseph Jones, doctor as a chief of the army confederated at the time of the American Civil war said “ I frequently saw the neglected wounds… grouillantes of larvae (…) these worms destroy only died fabrics, and save the healthy parts .”

• Dr. J.F. Zacharias, another officer confederated doctor, would be the first (Re) to have developed this technique of care, estimating at the time of the American civil war that, these “ larvae… in only one day cleans a wound well better than all the agents than we had at our disposal. I am sure to have saved many lives by their use”. Its patients treated with larvae would have actually profited from an high rate of survival.

• During the First World War, Dr. William S. Baer, orthopedic surgeon has in his turn identified on the battle field the effectiveness of the colonization of a certain larva of fly to cure certain wounds. It in particular brought back the case of a soldier who spent several days on the battle field without care, food nor water exposed to the elements with multiple fractures open of the femur and large wounds to the abdomen and the scrotum. When it arrived at the hospital, it however did not present any sign of fever in spite of the serious nature of its wounds. Once its removed clothing, it proved that “ thousands and thousands of larvae had colonized the totality of the wounded parts ”. With surprised of the doctor, after these larvae were removed “ it did not have there practically no naked bone to see and the internal structure of the wounded bone as the surrounding parts for the majority had been entirely covered with most beautiful pink fabric than one could imagine ”. This case is described at one time when the Antibiotique S were not known, and where 75 to 80% of the victims of multiple fractures of the femur would die in spite of the care that one could them give.

• In 1929, at the university of Johns Hopkins, this same Dr. Baer will pose maggots in the open lesions of 21 patients victims of incurable Ostéomyélite chronic by the means of the time. It observed the fast cleaning of the wounds, a reduction of the number of organizations Pathogène S, a reduction in the odor of the wounds, the alkalization of the wounds, and the cure of the totality of the lesions of the 21 cured patients, who left the hospital after 2 months of this therapy.

• After the publication in 1931 of the results of Dr. Baer, the asticothérapie was spread in the USA. The pharmaceutical company Lederle, produced and sold great quantities of “ surgical larvae ” of a fly called “ green bottle fly (Fly green bottle)” by English, Phaenicia sericata , re-elected since Lucilia sericata , necrophagous true, i.e. whose larvae with the difference in other species of Lucilia consume only fabrics necrotic.

• Of 1930 to 1940, more than 100 medical articles was published on the therapy by these larvae, with many descriptions of successful use, including for chronic or seriously infected lesions (of which case of osteomyelitis, Abcès, burns and Mastoïdite subacute), encouraging more than 300 American hospitals to use this therapy, until the discovery of the Pénicilline, then other antibiotics does not make consider out-of-date this technique.

• In 1954, at the time of the Battle of Diên Biên Phu, the French sanitary services find themselves overflowed by the surge of casualties who it is impossible to evacuate of the besieged fortified camp. A spontaneous asticothérapie will be set up, coming to mitigate the lack of drugs and relieving the surgeons and the male nurses of part of their spot, as the doctor ordering brings it back Grauwin in his deliver-testimony I were doctor at Diên Biên Phu .

Renewed interest

The generalized use of antibiotics in a few decades caused the selection of a growing number of bacterial strains and fungic nosocomiales (resistant then multi-resistant to antibiotics). In 1989, Dr. Ronald Sherman, doctor of the university of Irvine (California), created a dedicated service in the treatment by the maggots with the “ Veterans Affairs Medical Center ” Length Beach (California). It launched the first controlled clinical test there using maggots to look after ulcers of the spinal column among veterans. He for that used a selected stock of Lucilia sericata sold on the market like “medical larvae”. Successes of this clinical test among patients whose precedent treatments had failed started again the interest of the medical community for this therapy. In four years, more than fifty scientific articles described the medical use of maggots, bearing on 400 patients having been the subject of clinical studies, among six thousand treaties and indexed (for a possible long-term follow-up). According to this medical literature, 40% to 50% of the members thus treated were saved.

More than 3.000 doctors (of private clinics and hospital) in more than 20 countries use today this technique, which could usefully develop in the countries where the access to antibiotics is difficult and/or where the pathogenic stocks nosocomiaux one develop. In 2003, approximately 30.000 treatments were managed to 6.000 to 10.000 patients.

Position of the FDA in the USA

The medical larvae must be in the USA approved by the FDA which authorized ( Premarket notification 510 (K) 033391, January 2004 ,) Dr. Ronald Sherman to produce and sell larvae to look after the man or animals, on medical regulation, for certain indications (incurable necrotic infectious wounds and wounds of the soft fabrics, of which escarres, ulcers of venous damning up, ulcers neuropathic of the feet, and traumatisms noncurable or post-surgical wounds (" For debriding non-healing necrotic skin and software tissue wounds, including presses ulcers, venous stasis ulcers, neuropathic foot ulcers and non-healing traumatic gold post surgical wounds.")

The medical larvae are the first alive organizations Invertébré S authorized by the FDA for marketing at medical end. Nearly 500 health centres in the USA use this therapy.

Mechanisms of action

Larvae necrophagous, according to the medical literature:

• disinfects the wound while killing there out of the bacteria;
• stimulates the production of tissues cicatricial;
• cleans the wounds in an optimal way (better than the surgeon which damages alive cells, by curetant the wounds which it is obliged to increase and to make bleed). The maggot can work several tens of hours, where the surgeon had only time that the Anesthésie lasts, and of which the eye, even expert could not distinguish the cells alive from those coldly dead). The maggots are precise and eat only fabric necrosed and/or infected thus avoiding the risk of Gangrène (causes amputations) and of Septicémie S low registers often mortals.

The cicatrization is accelerated and the attenuated pain. It is plausible that the natural selection supported the larvae producing of the substances decreasing the Douleur or the Prurit, or else the host would seek to get rid some. The maggots which nourish flesh in decomposition bathe in a culture medium. It is also plausible that they secrete antibiotics. In this case, their use must be attentively supervised, because a new wave of microbial stocks nosocomiales resistant to the maggots (by infecting them for example) could appear. A polythérapie associating an antibiotic treatment remains possible.

The asticothérapie remains compatible with other types of care of which certain antibiotics. It is not compatible with the treatment of the wounds under negative pressure, but can precede it. Where the surgeon could not clean in real-time and in-depth, of the infections or a gangrene invading of fabrics 24 hours over 24,7 days out of 7 (the surgical cleaning of the wounds is made only one with twice per week), the maggots can clean without slackening, with good lower costs.

The larvae produce their food by “extracorporal digestion” thanks to a large range of Enzyme S proteolytic which liquefies necrotic fabric all while disinfecting it. The larvae absorb then to nourish fabric died in semi-fluid form of it, in a few days.
Dans a wound constituting for them an optimal environment, the larvae moult twice, passing from 1 to 2 millimetres with 8 to 10 millimetres into 3 to 4 days.

Disinfecting effect

Any infection of a wound is a serious medical complication. If the infectious stock is nosocomiale, it becomes difficult or impossible to treat the infection which becomes a danger to the member reached and the life of the patient.

The Asticot S generally effectively disinfect the wounds and wounds all while cleaning them, even if it is about Bactérie S resistant to antibiotics.

First experiments showed in vitro as of the years 1930 the antimicrobic character with broad spectrum of secretions of the Larve S. In 1957, an antibiotic factor was isolated in these secretions and described in the newspaper " Natural ". It is thought that are in particular implied Allantoïne, Urée, Phenylacetic acid , Phénylacétaldéhyde S, Carbonate of calcium and proteolytic Enzyme S. Bacteria not killed by these secretions are also introduced and lysed inside the larvae.

In vitro, the larvae were able to destroy a range of pathogenic bacteria including of variable of Staphylococcus aureus resistant to the Méthicilline and of the Streptocoque S of the group has and the group B, of the aerobic and anaerobic stocks grampositives.

Among five patients (cases published) victims of streptocoques resistant, after the 18 months failure of conventional therapy, the asticothérapie could eliminate the bacterium from all the wounds on average in 4 days.

Curative effect

Secretions of these maggots seem to accelerate the production by the cicatricial tissue host, via the production at the host of a growth factor of the skin. In vitro, the larvae stimulate the growth of the human fibroblasts and the chondrocytes with slow growth. Specific collagen II of cartilagineux fabrics increases in the body environment in the zones of secretion of the larvae. The microphone-massage induced by the movements of the maggots could also intervene. Researchers whose Dr. Ronald Sherman seek to elucidate the mechanisms in question.

The Allantoïne found in larval secretions (molecule used in many gel of shaving) has a calming effect on skin (ref.; Introductory chapter of Borror and Al, in " Year introduction to the study off insects" 6th ED.)

Application (bandages of larvae)

They must be permeable with the air because the larvae are Aérobie S. They are laid out in the wound where they must be able to be driven freely during 2 days. They can be contained in a kind of sealed pocket, placed on the wound. The larvae which ate enough are larger and seek to leave the wound. To remove the larvae of the wound considered cleaned well is easy. The operation is renewed every 2 days, until complete cleaning.

In Germany, the Hohensteiner institute seeks to develop bandages out of porous pocket provided with a nylon net containing the sterile worms resulting from culture, making it possible the larvae not to be crushed by the bandage, the whole protecting the sensitive patients from their vision. He also seeks to extract or synthesize the molecules excreted by this maggot to impregnate a bandage with it.

Veterinary care

In the world, many traditional veterinary medicines used maggots to clean dead fabric of animal wounds. It is a particularly effective method in the cases of osteomyelitis and ulcers chronic, and in the presence of any pus in wounds produced by the equipment of work.

In the USA, in 2003 Scott Morrison, veterinary specialist in the shoe at the Hospital for horses Rood and Riddle of Lexington (Kentucky), started to use the maggots to treat the horses, for the diseases of the shoe, or the complications, for secondary osteomyelitides, abscesses and ulcers, in actions postchirurgicales.

Evolution

A selective advantage is gotten for this fly, enabling him to survive while following the herds wild or domestic or in their environment, relative with the shelter of predatory, until the larvae can leave the wound, to fall on the ground and to transform themselves into Pupe S. One can speak about Symbiose or mutualism.

References

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