Friday, January 01, 2016

Maggots and wound debridement

I think I am enjoying CBBC's Operation Ouch rather more than my lad, who is within the target age group of CBBC!  This is a series about the body, medicine and health, and the presenters are doctors.

Today's edition included a journey with paramedics, a six year old visiting A and E having fallen on gravel, and bacteria being grown after people have kissed a Petri dish.

And sterile fly larvae being bred and used to treat wounds, with a warning before the footage was shown of a foot wound being debrided.  I remembered that this was a search topic we used to use in classes as an example to work on, as there are things to decide about search terminology (maggots, larvae?   wounds, debridement?).

I have an iPad to use in my clinical librarian post, with several apps to use on the ward.  What do they find? 

UpToDate: searching for maggots (I typed as much as "magg" and "maggots" appeared as the list of results) finds "Basic principles of wound management".  The literature review is current as of November 2015 (although there is a peer review process), and the last update to the topic was in May 2015.  The Find facility takes you to the section "Biologic", under "Wound debridement", which outlines uses of maggots.  RCTs have not found consistent reductions in the time to wound healing, although maggots compare well in terms of cost to hydrogel.  Maggots may reduce the duration of antibiotics in some patients, although there are negative perceptions associated with the use of maggots and pain may limit its use.

The NICE app: nothing found for "maggots" or "larval".   As you type a search term, results are shown, so there is nothing for "maggot" or "larvae" either.  Searching for debridement finds items (I got as far as "debrid") including "Wound care - debriding agents", from 2001.  Following this takes you to NICE Guideline CG74, "Surgical site infections: prevention and treatment", from 2008, which replaced it.  This seems more specific, and although I can't find a way to search the full text, there is no obvious sign of larvae.

PubMed for Handhelds: a quick use of the PICO search for P = wounds and I = maggots (or larvae or debridement) finds some useful looking results, although a change of search terms seems to make a lot of difference, and using "maggots or larvae" as the I finds a Cochrane review that I can't spot in searches for a single term.  I am not sure without checking what order results are shown in.  The Cochrane review turns up in a search of a final resource:

NICE Evidence Search: maggots, and filtering to systematic reviews, finds that Cochrane review (Debridement for venous leg ulcers, September 2015), as does a search for debridement.  It is also worth noting that NICE Evidence Search finds information in the BNF and about how to get hold of and dispose of maggots, which are available on the NHS.  That Cochrane review seems not be be referenced in UpToDate, but it was published very close to the last literature review, and the UTD peer review process may still be looking at it.   Having said that, it is not obvious from the abstract (viewed in PubMed itself) what the review has to say about maggots.  They are certainly investigated in some of the RCTs in the review, but in the abstract they are not clearly distinguished from other methods of debridement.

So, there is evidence there worth exploring.   You might need to use more than one source and which tool you use might determine what you find first, and what search terms you use may do the same. You will need some idea of what forms of evidence are viewed as the strongest, and will need to read the items you find in detail. 

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