APPENDIX 1
Clinical Practice
THE USE OF LARVAE IN WOUND MANAGEMENT
Definition: Sterile larvae of the common green-bottle (Lucilia sericata) are
used to treat most types of sloughy, infected or necrotic wounds. They may
also reduce wound pain and stimulate the formation of granulation tissue
(NHS Fife (2010) Wound Formulary and Wound Management Guidelines,)
1
POLICY STATEMENT
2
1.1
NHS Fife Community Health Partnerships (CHPs) acknowledge the use
of Larvae in the treatment of appropriately assessed wounds.
1.2
Only medical grade larvae currently on contract to NHSScotland must be
used for this purpose.
LOCATION
All clinical areas including domiciliary settings within NHS Fife.
3
RESPONSIBILITY
3.1
To ensure best practice in the application of larvae therapy, NHS Fife
CHPs will expect registered nursing/ pharmacy/ medical practitioners to
(where relevant to their role):
a) Carry out a full assessment of need which identifies the wound,
which would respond most appropriately to larvae therapy.
b) Ensure that the correct treatment of larvae therapy is given as
prescribed in collaboration with relevant medical, registered nursing
staff and pharmacy staff.
c) Ensure that treatment is consistent with NHS Fife Policy on
Obtaining Informed consent for Treatment (2009).
d) Supply patients with the appropriate patient information leaflet. (See
appendix C)
e) Accurately record the application, monitoring, removal and disposal
of the ‘Larvae’
f) Apply NHS Fife Infection Control Policy and Procedures
g) Larvae therapy must only be undertaken by a registered practitioner
who has had previous practical experience in the management of
wounds, and a thorough understanding of the wound healing
process.
h) Have undertaken an educational programme in larval therapy
(nursing staff only)
4.
OPERATIONAL PROCEDURE
4.1
4.2
Wound Assessment
4.1.1
Larvae Therapy is suitable for most types of infected, sloughy or
necrotic wounds irrespective of aetiology. The exceptions to this
are:
a) Fistulae;
b) Wounds that connect with the abdominal cavity;
c) Wounds that bleed readily;
d) Patients receiving anticoagulant therapy;
e) Wounds close to major blood vessels or nerves;
f) Any situations where blood supply is insufficient to permit
healing to take place.
4.1.2
Dry necrotic wounds require wound bed management prior to the
application of larvae in order to breakdown eschar formation
4.1.3
Prior to undertaking larvae therapy, the registered practitioner must
check for interactions/ contra- indications with other wound care
products e.g. hydrogels.
4.1.4
Larvae must only be used where the patient has given informed
consent to the use of this therapy. This must be clearly
documented in the patient’s nursing and medical records including
date of review.
Order, supply and storage of larvae
4.2.1
Larvae are available in two forms;
a) “Free-range” larvae (LarvaE), which are applied directly to the
wound
b) Or in “Bags” (BioFOAM); where the larvae are contained in
small fabric bags that are placed directly on the wound surface.
4.2.2
N.B. For ‘free range’ Larvae a retention system is required.
The following retention systems are available for use:
a) Nylon net dressings – for wounds that are isolated and easy to
dress;
b) Nylon net system sleeve – for extensive or circumferential
wounds (arm and legs);
c) Nylon Net Boot – for extensive wound on limb extremities
(hand, feet, stumps);
d) Half Boot – for toes.
N.B. Further guidance can be obtained from
www.biomonde.com/resources/literature
4.2.3
To calculate the number of larvae required:
4.2.3.1
For free range Larvae- a simple calculator can help to
determine the number of pots of Larvae required for the
wound (see Appendix A).
4.2.3.2
For BioFOAM- bags should be sized to allow overlap of
the wound margin (see Appendix B)
4.2.4
Larvae should be used on the day of delivery; in exceptional
circumstances, they may be stored overnight at room temperature
(in the delivery box) away from direct heat.
4.2.5
In Community settings
4.2.5.1
In community settings upon receipt of a prescription
(GP10/ GP 10 (N)) the Community Pharmacist can order
larvae by telephone 0845 230 1810 or fax 01656 668047
during working hours from Monday to Friday.
N.B The ability to manage larvae therapy must be
considered when commencing therapy i.e. weekend
cover required.
4.2.5.2
Orders received before 12.00 hours may be dispatched
by a courier for delivery (excluding Sunday) the following
day. Contact BioMonde on tel: 08452301810 or email
orders@biomonde.com for further advice.
4.2.5.4
When placing an order the following details are required:a) Delivery address for the surgery, pharmacy or
clinic;
b) The product required including order code;
c) Preferred date and time of delivery;
d) Address to which the invoice should be sent.
4.2.6
In Community Hospital settings
Larvae can be obtained via the Pharmacy Department at Victoria
or Queen Margaret Hospital.
4.2.7
4.2.8
Monitoring
4.2.7.1
Exudate production is often increased during larvae
therapy as the larvae liquefy the dead tissue and which
may be accompanied by an increase in wound odour.
This is only temporary and usually resolves after the first
dressing change.
4.2.7.2
Patients with ischaemic wounds/arterial disease/
neuropathy may complain of increased wound pain during
treatment. This is thought to result from changes in
wound pH.
4.2.7.3
If the pain experienced becomes a problem and cannot
be controlled adequately by analgesics, then the larvae
may be removed earlier than usual or moved to
alternative site in the wound bed where they maybe better
tolerated (bags only).
4.2.7.4
Outer bandages, absorbent padding and gauze must be
checked on a daily basis and changed if they become
excessively wet or malodorous.
4.2.7.5
Larvae can be left on a wound bed for 3 (free range) -5
(bags) days. If their growth rate is reduced it may be
appropriate to leave them an additional day.
4.2.7.6
In some instances if the wound is not sufficiently moist
the larvae may require additional humidification. This can
be undertaken by placing 5-10mls of sterile water or 0.9&
sodium chloride through the mesh.
4.2.7.7
For further advice and support (24hours) contact local
BioMonde representative on 07896 687010
Removal of Larvae from a wound
4.2.8.1
Larvae can be removed from the wound bed with a
gloved hand or a pair of forceps.
4.2.8.2
If the larvae have found their way into the depths of a
wound they will generally come to the surface if the
wound is irrigated with a stream of sterile water or 0.9 %
Sodium Chloride.
N.B. do not be concerned if all the maggots are not
returned
4.2.8.3
4.2.9
4.2.10
When all Larvae have been removed, reassess the
wound to see if further Larvae therapy is required or a
change to conventional therapy as indicated.
Disposal of Larvae
4.2.9.1
Larvae are regarded as Grade A medical waste for
incineration and must be disposed of in accordance with
NHS Fife Infection Control Manual (2010).
4.2.9.2
The special containers for disposal must be left with the
patient on application of the Larvae in the event they
require to be removed quickly.
4.2.9.3
In Hospital settings:
They should be placed in the supply containers which
convert into a clinical waste bin and disposed of in clinical
waste bags.
4.2.9.4
In Community settings:
They must be disposed of in the supply container and
double bagged in clinical waste bags.
Special uplift of the larvae requires to be arranged with
the transport department in the Area Distribution Centre
(01592 657335).
Patient Death
If a patient dies unexpectedly during Larvae therapy, the
Larvae should be removed from the wound prior to the
transfer of the patient to the mortuary and disposed of as
discussed in 4.2.9
4.2.11
Patient education
4.2.9.5 To gain informed consent and promote compliance it is
important that the patient has been provided with a
‘Patient Information Leaflet on Larvae Therapy’. (See
appendix C).
4.2.9.6
Patients must be provided with:
a) Details of who to contact during normal working
hours;
b) NHS 24 out with normal working hours including
bank holidays/ weekends;
In the event that removal is required.
4.2.9.7
5
RISK MANAGEMENT
5.1 Administering Nurse responsibility:
It is the responsibility of the administering nurse following any
adverse incident or near miss to:
a) Comply with NHS Fife (2010) COPM 15-1 and NHS Fife (2006)
Incident Management Policy and a Incident/Near Miss Reporting
Form must be completed and given to the line manager as soon as
practicable.
b) The nurse must report any symptoms that are unrelated to the
treatment to the patient’s General Practitioner (NMC, 2007).
c) The nurse must report any issues with larvae therapy to the
BioMonde clinical helpline tel: 08452306806
d) A “yellow card” must be completed if it is suspected that an adverse
reaction may be related to the larvae or a combination of medicines.
Further information can be obtained on the “yellow card” scheme
from http://yellowcard.mhra.gov.uk/
5.2
6
The patient must be advised to report any adverse
incidents to the nursing staff / GP.
Line Managers Responsibility:
It is the responsibility of the line manager following any adverse incident or
near miss to ensure that procedures are followed in accordance with NHS
Fife (2010) COPM 15-1 Management of Medication Incidents and NHS Fife
(2006) Incident Management Policy GP/12
REFERENCES
BioMonde resources accessed via www.biomonde.com
NHS Fife (2006) Incident Management Policy GP/I2 NHS Fife
NHS Fife (2009) Guidance on Obtaining Informed Consent to Treatment
NHS Fife. (2010) Infection Control Manual. NHS Fife
NHS Fife (2010) COPM 15-1: Administration of Medicine- Management of
Medication Incidents NHS Fife
NHS Fife (2010) Wound Formulary and Wound Management Guidelines, 4th
Edition, NHS Fife
Nursing and Midwifery Council, (2007). Standards for Medicines Management
London: NMC
7
APPENDICIES
Appendix A:- Larvae Calculator
Appendix B:- BioFOAM ordering guide
Appendix C:- Patient Information Leaflet Sterile Larvae Therapy
Appendix A
LarvaE Calculator
(www.biomonde.com)
Appendix B
Appendix C
PATIENT INFORMATION LEAFLET
STERILE LARVAE THERAPY
CONTACT DETAILS
For specific information on your wound you should contact:
PROFESSIONAL ________________________________________________
CONTACT DETAILS ____________________________________________
_______________________________________________________________
TYPE OF DRESSING SYSTEM IN USE____________________________
LENGTH OF TREATMENT____________________________________
Each application of Sterile Larvae is generally left in place for about three days. It is not possible to
predict how long a course of treatment will take.
Sometimes a wound is completely cleansed by a single application of Sterile Larvae but other wounds
may require two or more treatments to achieve the desired effect.
CHANGES IN YOUR WOUND DURING STERILE LARVAE THERAPY
You may experience some change in your wound during Sterile Larvae therapy;
The wound may become a little more wet than usual or show the presence of a dark red or pink
discharge. This is due to the action of the Larvae breaking down dead tissue in the wound;
Sometimes a wound that contains a lot of dead tissue will develop a smell during treatment. This is
due to the activity of the Larvae and should disappear when the dressing is changed;
Most people are unaware of the Larvae’ presence. A small number of people claim that they can feel
the Larvae moving but only describe this as a tickling sensation;
Some patients, particularly those with poor circulation report that their wounds become more painful
during Sterile Larvae therapy. This can usually be controlled with medication. Your doctor will be able
to advise you of the action to take in the event your wound becomes more painful.
Some patients have found that pain associated with infected wounds is reduced following Sterile
Larvae therapy.
ACTIVITY TO AVOID DURING STERILE LARVAE THERAPY
It is possible to carry out most normal activities whilst undergoing this therapy. Ideally you should not:

Bathe or immerse your wound in water, particularly in the early stages of treatment. Although
the Larvae are unlikely to drown excessive moisture can loosen the retaining dressing and allow
them to escape;

Sit with the wound too close to a fire or other source of heat as the Larvae may dry out;

Sit or walk on a wound dressed with Larvae as the Larvae will be squashed.
If you have any concerns when the Sterile Larvae are in place contact ___________
____________________________________________________as soon as possible.
APPENDIX 2
How many maggots have been used since they were first introduced – broken down by year and
supplier?
Description /
Year
MAGGOTS
MAGGOTS
(Biofoam)
DRESSING
2.5x4cm (1)
MAGGOTS
(Biofoam)
DRESSING 2x2cm
(1)
MAGGOTS
(Biofoam)
DRESSING 5x5cm
(1)
MAGGOTS
(Biofoam)
DRESSING 7x12cm
(1)
MAGGOTS
(Biofoam)
DRESSING 7x7cm
(1)
MAGGOTS BIO
BAG 2.5cm x 4cm
(BB50) (1)
MAGGOTS BIO
BAG 5cm x 6cm
(BB200) (1)
MAGGOTS, Larvae
(Large Biobag)
2003
2004
2005
2006
16
2
44
4
5
9
2007
2008
1
1
2009
2010
2011
5
2012
2013
2
1
1
ZOOBIOTICS
4
7
1
8
2
ZOOBIOTICS
5
9
3
3
1
ZOOBIOTICS
3
2
4
3
1
2
23
18
10
Supplier
SURGICAL
MATERIALS
LAB
ZOOBIOTICS
1
11
2014
ZOOBIOTICS
1
ZOOBIOTICS
ZOOBIOTICS
STRATHMANN
LIMITED
APPENDIX 3
How much has been spent on buying maggots?
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Cost
£1,124
£2,999
£4,837
£2,925
£2,250
£3,804
£1,733
£4,789
£976
£468
£1,106
£27,012
APPENDIX 4
How much has been spent on buying the honey and where is it bought from?
Drug Description
ACTIVON HONEY
PASTE 25g (12)
ACTIVON
MANUKA HONEY
TUBE 25g (12)
ACTIVON
MANUKA HONEY
TUBE 25g (1)
ACTIVON TULLE
10x10cm
DRESSING
ACTIVON TULLE
10x10cm
DRESSING
ACTIVON TULLE
5x5cm DRESSING
ALGIVON
ALGINATE10x10cm
DRESSING
ALGIVON
ALGINATE 5x5cm
DRESSING
MESITRAN
10x10cm
DRESSING
MESITRAN
10x10cm MESH
DRESSING
MESITRAN
17.5x10cm
DRESSING
MESITRAN
20x15cm
DRESSING
MESITRAN
BORDER 10x10cm
DRESSING
MESITRAN
BORDER 15x13cm
SACRAL DRESSING
MESITRAN
BORDER 15x15cm
MESITRAN
OINTMENT (15g)
MESITRAN
OINTMENT (50g)
MESITRAN S
OINTMENT (15g)
2005
2006
2007
2008
10
11
1
12
2009
3
2011
2012
2013
2
Supplier
ALLIANCE HEALTHCARE LTD
(002972)
AAH PHARMACEUTICALS
(000401)
110
0
2010
42
AAH PHARMACEUTICALS
(000401)
44
ADVANCIS MEDICAL
(001923)
7
20
50
170
410
280
155
77
74
ADVANCIS MEDICAL
(001923)
10
125
230
335
145
90
24
52
ADVANCIS MEDICAL
(001923)
245
485
805
565
290
ADVANCIS MEDICAL
(001923)
125
405
640
485
280
ADVANCIS MEDICAL
(001923)
920
1790
1650
1290
370
380
180
ASPEN MEDICAL EUROPE LTD
(000746)
620
1000
480
290
340
240
110
ASPEN MEDICAL EUROPE LTD
(000746)
20
30
10
10
50
20
10
AAH PHARMACEUTICALS
(000401)
40
10
60
40
40
20
20
AAH PHARMACEUTICALS
(000401)
160
210
160
80
10
10
10
10
30
10
10
174
351
235
39
1
4
25
29
34
48
21
14
11
5736.15
9234.83
8,861.04
8946.63
8543.16
6306.03
3486.46
ASPEN MEDICAL EUROPE LTD
(000746)
AAH PHARMACEUTICALS
(000401)
AAH PHARMACEUTICALS
(000401)
ASPEN MEDICAL EUROPE LTD
(000746)
AAH PHARMACEUTICALS
(000401)
AAH PHARMACEUTICALS
(000401)
10
174
56
89
60
1
1346.23
1454.45