The merits of maggot therapy

I was a medical student, finishing up my training in The Gambia, West Africa. One day I will write on the amazing things I saw over there. One is illustrated here. A farmer, with an infected foot, walked 100 km with a bandage on the wound. At some point, a fly laid its eggs in the wound, and by the time he arrived at MRC-Fajara, his foot was crawling with maggots. Before I could get a good picture, the nursing staff had cleaned most of them off, but one or two are still visible. The good news? The man left the hospital ALIVE, albeit with a below knee amputation. The maggots did their job, cleaning up the wound before invasive pathogens would take this man’s life. Read: The cases you never forget Fast forward to 2023. An article in the Guardian catches my attention. Amelia Tait writes on the merits of looking back at historic treatment options at a time when globally, resistance to antibiotics is a real concern (1) Bill Bryson, in his book The Body, a Guide for Occupants(2) harkens back to the serendipity that followed Alexander Fleming in 1928. Whilst a medical researcher at St Mary’s Hospital London, he had left agar plates on his desk, allowing spores of Penicillin Notatum to make landing on one hot summer’s day. The slow-growing mould exuded a material that inhibited bacterial growth, and Fleming made note (but took no immediate action). Australian Howard Florey, and subsequently German Ernst Chain, worked to make significant amounts of this wonderous material, and in 1941 they had enough to treat Mr. Albert Alexander’s advanced facial sepsis. Remarkable improvement occurred in two days, but when the supply was exhausted, the patient relapsed and died. Read: Medicine and radiology: what do we need to know? With the War in full swing, research facilities in Peoria (Illinois) looked for fungi with potential benefit. Mary Hunt’s cantaloupe had a ‘pretty golden mould’ on it, a proved to be a very potent source of antibiotic. Modern penicillins owe their lineage to her cantaloupe. Within a year, pharmaceutical companies were producing 100 billion units of penicillin a month. The point I want to make: in bygone days it took 40,000 units of penicillin to treat a pneumococcal pneumonia. Now it might take 20 million units a day, and of course some strains are completely resistant. Yes, we found methicillin to combat Staph Aureus, but now MRSA is becoming common-place. Vancomycin resistant MRSA and Carbapenem-resistant-Enterobacteraciae are the new killers on the block and mortality rates are rising. The pharmaceutical industry cannot realise a profit in looking for the next antibiotic. It takes a long time and a huge capital investment to find the next drug, one that might only be used for a week or two in small patient numbers. Patents don’t last long. That’s why they invest in statins, or anti-depressants, or immunotherapy agents that can make a better return on investment. Yes, we should have better antibiotic stewardship—including a ban on the indiscriminate use of antibiotics for cattle fattening, outlawed in the EU in 1997 but still prevalent in the USA. Maybe we need drugs that will activate only when a certain threshold of infection is present. Bacteriophages, viral agents that target bacteria, need more study. And we need to incentivize companies to take on this challenge to the existence of humanity, if we are to co-exist successfully with potentially lethal pathogens. Maybe we should also look back at treatments that were effective but became less ‘attractive’ when pills and infusions took over. Dr Ronald Sherman has studied and advocated for maggot therapy, a treatment that has helped soldiers in the Napoleonic wars, the American Civil War, and the First World War—in fact, a practice that dates back millennia. Do most people realise how effective maggots are at debriding devitalised tissue? There are companies out there making ‘medical-grade’ maggots, like BioMonde. The NHS, who accepted the use of maggot therapy in 2004, has seen a steady growth in this form of treatment. Nine thousand BioBags are sent to UK healthcare providers every year, each containing disinfected larvae in numbers corresponding to the magnitude of specific tasks. One day the ‘yuck factor’ may collapse as antibiotic resistance leaves us no alternative. Podiatrists have found maggot therapy to be “the quickest way to clean up a wound.” We may have few options left to us as the future unfolds. The down side? What would happen if the drug rep left some maggot samples in your office on a Friday, and you came back in on Monday, after a warm weekend? It doesn’t bear thinking about. References: 1. Medieval medicine: the return to maggots and leeches to treat ailments 2. Bill Bryson. The Body, A Guide for Occupants. ISBN 9780385685740 Doubleday Canada

The merits of maggot therapy

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