Treatment of Heel Wound Infested with Maggots
Sharp debridement is the preferred method for treating a heel wound infested with maggots, followed by appropriate wound care including dressing selection based on wound characteristics and pressure offloading.
Initial Management
Maggot Assessment and Removal
- Evaluate whether the maggots are therapeutic (sterile Lucilia sericata larvae intentionally applied) or wild maggots (unintentional infestation)
- For wild maggot infestation:
- Remove all visible maggots using forceps or irrigation with sterile saline
- Perform thorough sharp debridement to remove necrotic tissue, slough, and any remaining larvae 1
- Inspect wound carefully to ensure complete removal of all maggots
Wound Assessment
- Evaluate wound characteristics:
- Size, depth, and extent
- Presence of necrotic tissue or slough
- Signs of infection (erythema, warmth, purulence, odor)
- Vascular status of the foot
- Probe for bone involvement to rule out osteomyelitis
Debridement and Wound Care
Debridement
- Sharp debridement is strongly preferred over other techniques as it is more definitive and controllable 1
- Remove all necrotic tissue, slough, and foreign material
- Trim surrounding hyperkeratosis (callus)
- Benefits of proper debridement:
- Removes colonizing bacteria
- Aids granulation tissue formation
- Facilitates specimen collection for culture
- Enables examination of deeper tissues 1
Wound Cleansing
- Irrigate thoroughly with sterile saline after debridement
- Consider obtaining tissue specimens (not swabs) for culture before starting antibiotics if infection is suspected
Dressing Selection
- Choose based on wound characteristics:
- For dry/necrotic wounds: Continuously moistened saline gauze or hydrogels
- For exudative wounds: Alginates or foams
- For wounds requiring autolysis: Hydrocolloids 1
Pressure Offloading
Critical for Healing
- Total contact cast is considered the gold standard for plantar wounds 1
- For less severe cases, consider:
- Removable cast walkers
- Half-shoes
- Custom-made insoles (for those with foot deformities)
- Over-the-counter arch supports (for those without significant deformities)
Infection Management
Assessment for Infection
- Diagnose infection based on clinical signs:
- Local inflammation
- Erythema
- Warmth
- Purulence
- Odor
Antibiotic Therapy
- For clinically infected wounds:
- Mild infections: Oral antibiotics (e.g., amoxicillin-clavulanate, cephalexin) for 7-10 days
- Moderate to severe infections: Initial parenteral broad-spectrum antibiotics
- Adjust therapy based on culture results within 2-3 days
- Do not use antibiotics for clinically uninfected wounds 1
Special Considerations
Vascular Assessment
- Evaluate perfusion to determine if revascularization is needed
- For severe vascular disease, consider early revascularization rather than prolonged antibiotic therapy 1
Therapeutic Maggot Option
- If the wound has extensive necrotic tissue that is difficult to debride conventionally, consider therapeutic maggot debridement therapy (MDT) using sterile Lucilia sericata larvae 1
- Benefits of therapeutic maggots:
- Limitations:
Follow-up Care
Monitoring
- Inpatients: Daily assessment
- Outpatients: Every 2-5 days initially 1
- Look for:
- Resolution of local and systemic symptoms
- Reduction in inflammation
- Wound bed improvement
- Development of healthy granulation tissue
Common Pitfalls to Avoid
- Inadequate debridement of necrotic tissue
- Failure to properly offload pressure from the wound
- Inappropriate use of antibiotics for non-infected wounds
- Neglecting to assess vascular status
- Confusing therapeutic maggots with wild maggot infestation
- Delaying debridement while awaiting revascularization 1
Remember that proper wound care, debridement, offloading, and addressing any underlying infection are the cornerstones of successful management for a heel wound with maggot infestation.