Cath Lab Digest

   Researchers examined 13 consecutive diabetic patients between 18 and 80 with MRSA-colonized diabetic foot ulcers of at least three weeks duration. The study excluded those taking antibiotics specific for MRSA, those on anticoagulation therapy or those who required immediate systemic antimicrobial treatment or urgent surgical management. Study authors say none of the MRSA strains was multi-drug resistant or vancomycin resistant.

   Patients received sterile free-range larvae of the green bottle fly Lucilia Sericata on their MRSA-colonized ulcers for four days at densities of 10 larvae per 1 cm². Patients wore offloading devices and pressure relieving dressings to prevent damage of the larvae during treatment. Researchers did not use topical antimicrobial agents or growth factors on the ulcers, according to the study.

   Researchers note that MRSA colonization was eliminated from 12 of 13 ulcers after a mean of three applications with a mean duration of 19 days, according to the study. Study authors noted no adverse events during the treatment. They also detected a reduction in sloughy necrotic tissue and an increase of granulation tissue upon removal of the last larval application.

   The maggot therapy lasted a mean of three weeks, which researchers note is much shorter than the conventional 28-week treatment for MRSA decontamination of diabetic foot ulcers. As the study notes, the mean wound area was smaller at the end of the study but the reduction in size was not significant in comparison to the baseline. They attribute this to the short duration of larval treatment.

   Study co-author Frank Bowling, DPM, notes that larvae are relatively cheap and do not have side effects. There are also no contraindications to maggot debridement on the foot, according to Dr. Bowling. He says a randomized clinical trial on the use of larval therapy in wounds with MRSA is currently under way.

   Eric Espensen, DPM, expresses skepticism as to whether maggot debridement would be effective for MRSA. While he does believe larval debridement would be effective as an adjunctive treatment to antibiotic therapy, since such debridement would remove necrotic tissue and slough, he does not feel larval therapy would be effective on its own. Given today’s medicolegal environment, Dr. Espensen says he always defers to the Infectious Diseases Society of America (IDSA) protocols.

Is Patient Reluctance A Factor?

Would patients be reluctant to undergo larval debridement due to the nature of maggots? Patients who receive such debridement are “at the stage were they will try any type of treatment to heal the wound,” according to Dr. Bowling, who is affiliated with the University Department of Medicine and Diabetes at Manchester Royal Infirmary in Manchester, U.K.

   When it comes to using maggot debridement in wound care, Dr. Espensen says he often hears objections from floor nurses in the hospital. Despite the fact that Dr. Espensen uses medical grade larvae, he notes the nurses cite concerns with sterility and the perception that maggots and flies are dirty. However, he notes most of his patients do not mind the treatment and become interested when he starts explaining the historic background and scientific basis for maggot debridement.

   “Always speak to the patient on his or her level in plain terms and simple terminology, and explain why you want to use them, the historical background and the effectiveness. I have never had a patient flat out refuse,” says Dr. Espensen, the Chief of Foot Surgery at Providence St. Joseph Medical Center in Burbank, Calif.

Study: Duloxetine Can Relieve Night Pain, Sleep Interference

By Brian McCurdy, Senior Editor

   Night pain that makes it difficult to sleep can often go hand in hand with the troubles spurred on by painful diabetic neuropathy. A relatively new medicine has shown promise in relieving night pain associated with sleep interference, according to an abstract that was recently presented at the American Pain Society meeting.