ANALISA JURNAL ILMIAH/ STUDI LITERATUR

Disusun untuk memenuhi tugas analisis jurnal

Oleh :
Nama: APRIS TIANA
NIM: 030520421
PROGRAM PENDIDIKAN PROFESI NERS
INSTITUT MEDIKA Drg. SUHERMAN CIKARANG

FORMAT
 ANALISA JURNAL ILMIAH/ STUDI LITERATUR
A. IDENTITAS JURNAL
Nama Jurnal :Jurnal Biomedik (JBM)
Judul :Terapi Larva Pada Luka Kronis Terbuka
No :1 Maret 2015
Volume :7
Penulis :Sunny Wangko
B. HASIL ANALISIS
No Kriteria Jawab Pembenaran & Critical thinking

1 P Ya Besarnya biaya pengobatan luka

(Problem/ Population) kronis di negara maju maupun
negara terkebelakang.

2 I Ya Terapi Larva
(Intervention)
Terapi larva dapat mempercepat
penyembuhan luka kronis,
menurunkan masa penggunaan
antibiotik, mengurangi masa
perawatan di rumah sakit, menu-
runkan risiko amputasi,
menurunkan jumlah kunjungan
pasien rawat jalan, relatif
ekonomis, dan memperbaiki
kualitas hidup.

3 C Ya Pada jurnal Jurnal Biomedik

(Comparation)
dijelaskan bahwa Larva
bergerak pada permukaan luka
sambil menyekresi sekret yang
berpotensi memecahkan dan
mencairkan jaringan nekrotik.
Sedangkan pada Journal
Complilation dijelaskan bahwa
larva memakan jaringan
nekrotik, puing-puing seluler
dan eksudat di dalam luka,
sehingga debriding dari devi-
jaringan talised.
 4 O Ya Hasil penelitian menunjukkan
(Outcome)
pasien dengan luka kronis yang
tidak menyembuh jarang menolak
untuk diberikan terapi larva.
Indikasi untuk terapi larva ialah
luka kronis yang tidak menyembuh
disertai jaringan nekrotik. Sebagai
contoh: ulkus akibat tekanan, ulkus
venosa, , luka traumatic.
Terapi larva mudah diaplikasikan,
relatif tidak mahal, dan tidak merusak
flora normal dalam saluran cerna, atau
meninggalkan residu yang merugikan
seperti halnya antibiotik sistemik.11,16
Larva harus digunakan dalam 8 jam
setelah erupsi dan disimpan pada suhu 8-
100C

C. KESIMPULAN

Terapi larva telah dikenal sejak berabad-abad yang lalu. Dengan dite-
mukannya antibiotik dan tehnik perawatan luka serta pembedahan yang lebih baik
maka terapi larva ditinggalkan. Akibat terjadinya resistensi bakteri terhadap
antibiotik maka terapi larva direintroduksi dan pada tahun 2004 telah diakui oleh
FDA untuk pemakaian pada luka kronis terbuka.
Awalnya diduga terapi larva bermanfaat hanya sebagai debridemen mekanis,
tetapi hasil-hasil penelitian melaporkan adanya berbagai bahan yang diduga turut
membantu penyembuhan luka, antara lain enzim proteolitik, bahan antibakteri,
growth factors, dan sitokin.
Terapi larva digunakan pada luka kronis terutama yang telah gagal dengan
terapi konvensional. Dengan dikembang- kannya molekul bioaktif yang terkandung
dalam bahan sekresi dan ekskresi larva diharapkan terapi larva dapat digunakan
secara luas untuk mendapatkan hasil yang lebih optimal dengan biaya yang cukup
ekonomis.

D. REFERENSI
https://ejournal.unsrat.ac.id/index.php/biomedik/article/view/7289
 TERAPI LARVA PADA LUKA KRONIS
TERBUKA
Sunny Wangko

Bagian Anatomi-Histologi Fakultas Kedokteran Universitas Sam Ratulangi Manado Email:

sunnywangko@yahoo.com

Abstract: The usage of larvae in wound treatment has been known across the centuries in
different countries. However, larval therapy is offered when the conventional therapy has
failed in the management of chronic, infected wounds. Concerning the larval therapy, it was
presumed that the wound healing was due to the mechanical debridement effect of the larval
movement and of their hooks. To date, a variety of study reports reveals that there are several
beneficial effects of the larval therapy, inter alia: secretion/excretion of larvae contains
enzymes, growth factors, and cytokines that collaborate in the wound healing process. The
bioactive molecules in the secretion/excretion of the larvae has to be further studied and to be
developed, therefore, they can be applied in the wound management efficiently and
economically. Keywords: larval therapy, chronic wound, healing process.

Abstrak: Walaupun pemanfaatan larva pada luka kronis telah sangat lama dikenal di berbagai
negara, terapi larva umumnya digunakan bila terapi konvensional telah gagal. Awalnya
diduga bahwa efek debridemen mekanis oleh gerakan larva dan kaitnya yang paling berperan.
Dewasa ini, laporan berbagi studi telah mengungkapkan bahwa larva menyekresi dan
menyintesis berbagai bahan baik berupa enzim, sitokin, dan growth factors yang turut
berperan dalam proses penyembuhan luka. Adanya molekul bioaktif dalam ekskresi dan
sekresi larva perlu diteliti dan dikembangkan agar dapat diaplikasikan dengan lebih efisien
dan ekonomis. Kata kunci: terapi larva, luka kronis, penyembuhan luka.
Umumnya larva serangga lebih dikenal dari Prancis pada abad ke-16 dan abad ke 18- 19.
dampak yang merugikan kehidupan manusia Terapi ini mulai ditinggalkan sejak
antara lain: sebagai hama tanaman, penyebab ditemukannya antibiotik (1940), tetapi
miasis pada manusia dan hewan ternak, kemudian setelah terjadinya peningkatan
mengganggu kenya- manan, dan merupakan resistensi kuman terhadap antibiotik terapi
bentuk pradewasa dari serangga sebagai larva ditinjau kembali,1,2 terutama pada luka
vektor penyakit. Pada hakekatnya, larva kronis yang terinfeksi oleh methicillin-
sangat berperan dalam kehidupan manusia. resistant Staphylococcus aureus (MRSA) dan
Daur ulang (recycling) sampah, tanaman patogen yang resisten lainnya.3
rusak, serta bangkai dan mayat,
Awalnya, masalah yang dihadapi pada
keikutsertaannya dalam rantai makanan, dan
terapi larva ialah bagaimana memperoleh larva
pemanfaatan dalam berbagai komoditi
yang steril dan hidup (medical- grade). Dengan
misalnya larva ulat sutera menunjukkan
kemajuan teknologi, larva yang digunakan
manfaat larva terhadapan kehidupan. Dewasa
lebih terjamin kualitasnya dan telah dijinkan
ini, pemanfaatan larva, khususnya larva lalat,
oleh USA Food and Drug Administration
telah ditinjau kembali untuk perawatan luka
(FDA) pada tahun 2004.2,4 Sejauh ini larva yang
terutama luka kronis terbuka yang telah
umum digunakan ialah larva lalat Lucilia
memboroskan biaya pengobatan yang cukup
sericata yang bersifat nekrofagus.1-3,5-9
tinggi baik di negara maju maupun negara
terkebelakang. Terdapat beberapa istilah yang dipakai
Pemanfaatan larva dalam perawatan luka untuk perawatan luka terbuka dengan
(terapi larva) sebenarnya telah dikenal sejak menggunakan larva yaitu: terapi larva, larval
berabad-abad yang lalu, kemudian therapy, maggot debridement therapy/MDT,
dikemukakan oleh beberapa ahli bedah di biosurgery, biodebridement, dan controlled
therapeutic myasis.2,5-7,9 Telaah ini bertujuan
untuk mengemukakan keunggulan terapi larva
yang sejauh ini belum dimanfaatkan di
Indonesia.
SEJARAH
Pemanfaatan larva dalam perawatan dan
pengobatan luka kronis terbuka telah dikenal
sejak berabad-abad lalu.1,3,10,11 Perawatan luka
dengan menggunakan larva pertama kali
dikenal pada suku Maya Indian di Amerika,
penduduk
aborigin Australia,2,11,12 dan di Cina.2,5 Pada
abad ke-16 (1557), Ambroise Pare
(seorang ahli bedah kekaisaran Prancis
Charles IX dan Henri III) melaporkan
manfaat larva pada luka-luka prajurit
selama perang.5,11
Pada abad ke 18-19 (1829) Baron
Dominique Jean Larrey (seorang ahli
bedah zaman Kekaisaran Napoleon) yang
pertama melaporkan secara tertulis bahwa
larva hanya menyerang jaringan nekrotik
dan terapi larva dapat meningkatkan
pembentukan jaringan granulasi serta
memicu penyembuhan luka terinfeksi yang
ditemukan pada prajurit.2,5,11 Selama
perang saudara di Amerika, Joseph Jones
dan J. F. Zacharias (ahli bedah sekutu)
mulai menggunakan larva untuk peng-
obatan luka dan mencatat bahwa dalam
beberapa hari larva telah membersihkan
luka jauh lebih baik dari bahan-bahan yang
direkomendasikan saat itu.2,5,6,11
Pada era pre-antibiotik (1920-an dan
1930-an), studi mengenai terapi larva
pertama kali dikemukakan oleh William S.
Baer (1929), seorang ahli bedah ortopedik
dari John Hopkins Hospital di Baltimore,
Maryland.5,8,10,11 Bear menggunakan larva
yang steril untuk mengobati luka-luka
prajurit selama perang dunia I dan
melaporkan bahwa luka pada fraktur
terbuka dan luka pada abdomen yang
dinfestasi beribu-ribu larva
memperlihatkan pertumbuhan jaringan
granulasi yang sehat. Juga pada kasus
osteomielitis anak, terapi larva
menghasilkan debridemen yang cepat,
menurunkan jumlah bakteri, mengurangi
bau, dan alkalinisasi alas luka.2 Dalam era
tersebut, mortalitas luka jenis demikian
mencapai hampir 75%.11 Sekitar tahun
1935, terapi larva telah digunakan pada
banyak rumah sakit di Amerika, Kanada,
dan Eropa.5 Terapi larva juga digunakan
pada ulkus mamae, luka bakar, abses,
karsinoma sel skuamous, dan mastoiditis
subakut.11 Kendala pada saat itu (tahun
1930-an) ialah menyiapkan kemasan untuk
aplikasi larva, kesulitan memperoleh larva
bebas kuman yang hidup, dan biaya yang
tinggi ($5 pada 1933).8 Dengan adanya
kemajuan dalam tehnik pembuatan
pembalut dan perekat yang lebih nyaman
(seperti cage-like dressings) serta dapat
mempertahankan larva pada alas luka;
desinfektan dan tehnik rearing yang sangat
mendukung produksi larva yang medical-
grade; dan transportasi yang menjamin
pengiriman larva ke lokasi, diharapkan
terapi larva akan dapat digunakan secara
lebih luas.8
Pada era antibiotik (perang dunia II),
dengan ditemukannya antibiotik penicillin
oleh Alexander Flemming (1928)2 dan
sulfa yang ampuh terhadap berbagai jenis
bakteri dan didukung oleh tehnik
pembedahan yang lebih baik, maka pada
tahun 1940 terapi larva mulai diting-
galkan.1,8,10,11 Munculnya resistensi ber-
bagai strain kuman terhadap antibiotik dan
meningkatnya insidensi luka dengan
vaskularisasi yang kurang memicu
reintroduksi terapi larva pada tahun1980-
an di Amerika, Inggris, dan negara Eropa
lainnya.1,2,8 Pada tahun 1990-an, Sherman
et al di Amerika Serikat dan Mumcouglu
et al di Israel mereintroduksi terapi larva
untuk pengobatan luka kronis.6
Pada tahun 2004, US Food and Drug
Administration telah mengijinkan
penggunaan terapi larva dengan indikasi
debridemen untuk luka kulit kronis dengan
jaringan nekrotik dan luka pada jaringan
ikat, termasuk ulkus akibat tekanan
(pressure ulcer), ulkus stasis venosa, ulkus
neuropatik pada kaki, dan luka pasca
operasi yang tidak menyembuh.2,4
 LUKA KRONIS kontaminasi saat diaplikasikan pada luka. Larva
diperlihara pada lingkungan yang lembab dan steril untuk
Dengan bertambahnya usia harapan mendapatkan larva yang medical grade.5,11 Telur dicuci
dengan larutan antiseptik dan ditempatkan di dalam wadah
hidup maka jumlah pasien dengan luka steril yang berisi brewer’s yeast dan kedelai sebagai
kronis akibat berbagai penyakit, terutama sumber makanan agar larva tetap bertahan hidup sampai
diabetes melitus dan penyakit pembuluh dapat ditranspor dalam wadah steril untuk kebutuhan
terapi larva.11
darah perifer turut meningkat. Luka kronis
tidak mengikuti fase-fase penyembuhan
luka, tetapi akan berhenti pada fase
inflamasi akibat adanya debris nekrotik
dan infeksi.2,5
Debridemen ialah tindakan
mengeluar- kan debris asing nekrotik atau
jaringan terkontaminasi dari alas luka
(wound bed) sehingga jaringan sekitar
yang sehat akan terbuka. Debridemen
dapat dilakukan dengan berbagai cara.
Salah satu cara yang telah lama dikenal
ialah maggot debridement therapy (MDT)
atau terapi larva. Dalam hal ini, larva lalat
yang medical-grade diaplikasikan pada
luka untuk menghasilkan debridemen,
desinfeksi, dan penyembuhan luka
(artificially induced myasis).2,3,5
DESKRIPSI LARVA YANG DIGUNA-
KAN PADA TERAPI LARVA
Umumnya yang digunakan untuk
terapi larva ialah larva Phaenicia
(Lucilia) sericata (Ordo Diptera, famili
Calliphoridae), yang tergolong dalam
green bottle fly (Gambar 1).2,3,5-9 Larva
hanya memakan jaringan nekrotik dan
tidak mengganggu atau menyusup ke
dalam jaringan sehat. Phormia regina
(blackbottle fly) juga dilaporkan dapat
digunakan untuk
terapi larva.6,11
Siklus hidup Phaenicia (Lucilia)
sericata

berlangsung sekitar 10-14 hari. Telur menetas

setelah sekitar 12-24 jam. Pertumbuhan larva dari instar 1
sampai dengan instar 3 (wondering larval stage)
berlangsung selama beberapa hari (3-7 hari) hingga
mencapai ukuran sekitar 10 mm, kemudian larva
(prepupa) akan mencari tempat untuk melakukan pupasi.
Masa pupasi berkisar 7-20 hari, tergantung pada suhu dan
cuaca (Gambar 2).5,6,8,9
Larva yang akan digunakan untuk terapi larva harus
steril (bebas bakteri) untuk mencegah terjadinya

Pada terapi larva, sekitar 5-10 ekor
larva diaplikasikan per cm2 luka.7,8,9,11
Larva yang digunakan ialah instar 1 ber-
ukuran panjang sekitar 2 mm (1-3 mm)
dan dapat berkembang menjadi 8-10 mm
setelah 5-7 hari. Selama 48-72 jam larva
bergerak pada permukaan luka sambil
menyekresi sekret yang berpotensi
memecahkan dan mencairkan jaringan
nekrotik.7,8,11 Larva dapat digunakan
bersama antibiotik sistemik, dan juga tidak
memperlihatkan efek merugikan pada X-
ray sehingga larva dapat dibiarkan pada
tempatnya saat dilakukan tindakan
tersebut.11
MANFAAT TERAPI LARVA
Manfaat terapi larva telah dilaporkan
oleh berbagai studi yang tersebar di
seluruh dunia. Terapi larva dapat
mempercepat penyembuhan luka,15
menurunkan masa penggunaan
3,10
antibiotik, mengurangi masa perawatan
di rumah sakit,6-8 menu- runkan risiko
amputasi,3,6,10 menurunkan jumlah
kunjungan pasien rawat jalan, relatif
ekonomis,3 dan memperbaiki kualitas
hidup.6 Beberapa kondisi pada terapi larva
yang membantu penyembuhan luka kronis,
yaitu:
1. Debridemen: Gerakan-gerakan
mekanis dari larva dengan kaitnya
pada permukaan sampai alas luka
berfungsi sebagai debridemen yang dapat
membersihkan luka dari jaringan nekrotik
dan terinfeksi.4,5,9 Studi Opletalova et al.4
mendapatkan hasil debridemen dengan
terapi larva lebih cepat dibandingkan
terapi kon- vensional lainnya.
Dibandingkan cara debridemen lainnya
seperti hydrogel dressings, pengolesan
madu, debri- demen mekanis atau
hydrosurgery, terapi larva
memperlihatkan efisiensi ekonomis yg
signifikan.16
1. Membersihkan jaringan nekrotik:
Larva menghasilkan berbagai enzim
proteolitik antara lain kolagenase yang
memecahkan jaringan nekrotik dan
matriks ekstrasel (termasuk laminin dan
fibronektin) Chan menjadi bentuk
semisolid yang dapat diabsorpsi dan
dicernakan oleh larva.4,5,9,11 2. Desinfeksi
luka: Larva memakan debris yang
terinfeksi, menghasilkan bahan
bakterisidal yang berspektrum luas
terhadap bakteri Gram positif dan negatif,
antara lain strain bakteri Staphylococcus
sp. termasuk methicillin-resistant
Staphylococcus aureus (MRSA),
Bacillus sp., Escherichia Coli,
Pseudomonas sp., Proteus sp.,
Enterococcus sp., dan
Enterobacter sp.2,3,5,7 Larva juga
menghasilkan amonia yang menye- babkan
alkalinisasi, diduga dapat menghambat
pertumbuhan bakteri.5,8
1. Irigasi luka oleh eksudat yang distimu-
lasi oleh larva yang menelan jaringan
nekrotik dan oleh sekret larva sendiri.3
2. Inhibisi dan eradikasi biofilm.
Chymotrypsin dan DNAse dalam
sekret larva dapat memecahkan
protein yang menyusun biofilm.2,4
3. Menghasilkan growth factors: Larva
menghasilkan alantoin, urea, dan
bahan lainnya yang dapat bekerja
sbagai
growth factors.2,4,6,10
4. Menghasilkan sitokin, antara lain
inter- feron dan interleukin 10 yang
diduga mempercepat penyembuhan
luka.5
5. Menghambat respons proinflamasi
monosit melalui peningkatan cilik
AMP oleh bahan yang disekresi dan
diekskresi oleh larva.8
6. Menghambat proses inflamasi melalui
pemecahan komponen komplemen
yang berakibat turunnya aktivitas
komplemen.2
7. Meningkatkan migrasi fibroblas.2,5
8. Berefek angiogenesis.2,7
INDIKASI TERAPI LARVA
 Umumnya pasien dengan luka kronis
yang tidak menyembuh jarang menolak
untuk diberikan terapi larva.3,6
Indikasi untuk terapi larva ialah luka
kronis yang tidak menyembuh disertai
jaringan nekrotik. Sebagai contoh: ulkus
akibat tekanan, ulkus venosa, ulkus
diabetik, ulkus neuropatik (non-diabetes),
ulkus iskemik/arterial, luka traumatik, luka
bedah, tromboangitis obliterans, luka/ulkus
pasca trauma, necrotizing fasciitis,
pioderma gangrenosum, abses pada
maleolus, osteomielitis sinus pilonidal,
luka infeksi pasca bedah, luka akibat
proses keganasan, luka bakar disertai
infeksi MRSA, dan
mastoiditis subakut.5,6
KONTRAINDIKASI
Terdapat kontraindikasi relatif dan
kontraindikasi absolut untuk terapi larva.
Yang termasuk kontraindikasi relatif yaitu:
1. Luka yang kering, karena larva
memerlukan lingkungan yang
lembab. 5
2. Pasien yang tidak
memahami penggunaan terapi larva.6
3. Luka yang membutuhkan inspeksi
yang sering.6
Yang termasuk kontraindikasi absolut yaitu:
1. Luka terbuka yang berhubungan
dengan kavitas tubuh atau organ
dalam.5,9
2. Luka yang dekat dengan pembuluh
darah besar.5,9
3. Luka yang mudah berdarah.5,9
4. Tulang atau tendon yang nekrotik.6
5. Gangguan perdarahan (herediter atau
farmakologik).6
6. Luka yang kurang
vaskularisasi (peripheral vascular
disease).6
7. Alas luka yang ditutupi kerak keras.6
8. Fistula yg belum dilakukan tindakan
pembedahan.6
9. Alergi terhadap telur, kedelai,
brewer’s yeast, dan larva.5
10. Semua keadaan dimana debridemen
merupakan kontraindikasi.6
EFEK SAMPING TERAPI LARVA
Selama pemberian terapi larva, efek samping yang
sering ditemukan, antara lain:
1. Rasa tidak nyaman (yuk factor) baik
untuk pasien, dokter, dan tenaga medis
lainnya.5,6
2. Nyeri: Mumcouglu et al.17 melaporkan
selama terapi larva nyeri ditemukan
41% pada pemakai tea-bag like pouch
(TBA) dan 38% pada pemakai cage-
like dressing (DA). Pemberian
analgetika dilakukan dengan titrasi
dosis, dan bila diperlukan dapat
dilakukan blok saraf tepi. Courtenay et
al.10 mendapatkan keluhan nyeri
ringan sampai berat (umumnya nyeri
sedang) 48-72 jam setelah larva
diaplikasikan pada luka; nyeri dapat
diatasi dengan analgetika.
3. Perdarahan ringan.10
4. Pireksia: Terjadinya pireksia belum
jelas, mungkin berhubungan dengan
reaksi imunologik.5,10
5. Influenza-like symptoms (pireksia,
malaise, keluhan saluran napas).10
6. Alergi terhadap bahan hidrokoloid
pada pembalut.10
7. Munculnya bau yang tidak enak pada
aplikasi larva yang pertama kali,
terlepasnya larva, atau larva yang mati
akibat tekanan pembalut.5
KOMPLIKASI
Komplikasi yang berat tidak pernah dilaporkan.3,5
KEMASAN
Terapi larva mudah diaplikasikan, relatif tidak
mahal, dan tidak merusak flora normal dalam saluran
cerna, atau meninggalkan residu yang merugikan seperti
halnya antibiotik sistemik.11,16 Larva harus digunakan
dalam 8 jam setelah erupsi dan disimpan pada suhu 8-
100C.9,18
Secara umum terdapat 2 kelompok kemasan larva
yang tersedia untuk aplikasi klinis: free-range dan bio-
 bag (BioMonde). Pada kemasan free range, larva
diaplikasikan langsung pada luka. Setiap aplikasi harus
diganti setelah 3 hari. Kemasan ini sangat sesuai untuk
luka yang bergaung atau berongga.2,9,18 Bio-bag berupa
kantong yang terdiri dari jaring poliester halus dengan
sepotong foam untuk menyerap sekresi larva yang
berlebihan. Kemasan bio-bag lebih praktis dan estetik,
serta sesuai untuk pasien rawat jalan untuk menjamin
tidak terlepasnya larva. Bio-bag
harus diganti setelah 4 hari.9,18
Dengan kemajuan teknologi, telah
dikembangkan berbagai kemasan larva,
antara lain: single-piece, hinged, dan cage-
like dressings. Kemasan demikian disebut
maggot confinement dressings yang
memberi akses pada larva ke luka secara
bebas tetapi dapat mencegahnya untuk
terlepas keluar.8
SIMPULAN
Terapi larva telah dikenal sejak berabad-abad yang
lalu. Dengan dite- mukannya antibiotik dan tehnik
perawatan luka serta pembedahan yang lebih baik maka
terapi larva ditinggalkan. Akibat terjadinya resistensi
bakteri terhadap antibiotik maka terapi larva
direintroduksi dan pada tahun 2004 telah diakui oleh
FDA untuk pemakaian pada luka kronis terbuka.
Awalnya diduga terapi larva bermanfaat hanya
sebagai debridemen mekanis, tetapi hasil-hasil penelitian
melaporkan adanya berbagai bahan yang diduga turut
membantu penyembuhan luka, antara lain enzim
proteolitik, bahan antibakteri, growth factors, dan
sitokin.
Terapi larva digunakan pada luka kronis terutama
yang telah gagal dengan terapi konvensional. Dengan
dikembang- kannya molekul bioaktif yang terkandung
et al. Maggot therapy for wound
debridement A randomized multicenter
trial. Arch Dermatol. 2012;148(4):432-
7.
5. Chan DCW, Fong DHF, Leung JYY,
PAtil NG, Leung GKK. Maggot
debridement therapy in chronic wound care.
Hong Kong Med J. 2007;13(5):382-6.
6. Pearson C. Something old is new again:
Debriding and reducing local wound
infection with maggots. Wound Care
Canada. 2007;5(2):22-6.
7. Rafter L. Larval therapy applied to a large
arterial ulcer: an effective
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8. Singh NM, Bhatia SK, Singh G. Maggots
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dalam bahan sekresi dan ekskresi larva diharapkan terapi
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hasil yang lebih optimal dengan biaya yang cukup
ekonomis.
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1. Steenvorde P, Jacobi CE, van Doorn L,
Oskam J. Maggot debridenet therapy of
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influencing outcome – A study on 101
patients withy 117 wounds. Ann R Coll
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Jung W, Nibbering PH. Multiple actions
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3. Sun X, Jiang K, Chen J, Wu L, Lu H,
Wang A, et al. A systematic review of
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International Joournal of Infectious
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4. Opletalova K, Blaizot X, Mourgeon B,
Chene Y, Creveuil C, Combemale P,
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2007;2:156-9.
10. Courtenay M, Church JCT, Ryan TJ.
Larva therapy in wound management.
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11. Hinshaw J. Larval therapy: A review of
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World Wide Wounds. October 2000.
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15. Armstrong DH, Salas P, Short B, Martin
BR, Kimbriel HR, Nixon BP, et al.
JURNAL INTERNASIONAL
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in wound management. Bath: Royal
United Hospital Bath, 2012
 doi: 10.1111/j.1742-1241.2006.01238.x

REVIEW ARTICLE

Larval therapy in wound management: a review

A. Parne´s,1 K. M. Lagan2
aureus (MRSA) and the curiosity of
Introduction
researchers has prompted a resurgence of
Despite advances in wound care, the increasing inci- interest in larval therapy (6). As a treatment dence of
chronic wounds and their numerous socioe- it meets the demands of clinical governance, conomic
consequences have made wound management being not only beneficial to the patient, but also a key area
of focus for health profes- sionals. Several being proven to be more cost-effective (7). thousand pounds
are devoted annu- ally to research in However, application of larval therapy has this area (1). been stifled
by aesthetic con- siderations.
Debridement is an essential component of wound care, as the ‘necrotic burden’ supported by devital-
Applications of larval therapy ised tissue impedes the healing process (2,3). In recent Whilst the
effects of therapeutic myiasis were ini- years there has been renewed interest into the use of tially recorded
in suppurative wounds on the bat- maggots for biosurgical debridement. tlefield, numerous case studies have
reported its
Larval therapy (or sometimes known as thera- successful use with a variety of wounds. Larval peutic
myiasis) is by no means a modern idea, having therapy has been employed effectively to treat been used
for several hundred years in wound healing a wide spectrum of wounds including venous and by several
cultures, including Mayan Indians and arterial leg ulcers, osteomyelitis, necrotising Australian aborigines (4).
The benefi- cial effects of fasciitis, traumatic necrotic leg wounds, primary therapeutic myiasis were first
observed during the burns, pressure sores and amputation sites Napoleonic war by Larrey, who noted that
soldiers including digi- tal amputations in diabetic feet whose wounds had become infested with maggots
had (8). Larval therapy has also been used for the an improved prognosis. During the First World War,
treatment of a variety of intractable wounds, Baer documented the successful treatment of leg including
sacral and leg ulcers of assorted ulcers and osteomyelitis using larval therapy, and aetiologies (9). Case
studies have reported the paved the way for further use of it by doctors of that successful use of larval
therapy to treat a wide time. However, the development of antibiotics and variety of wounds including
chronic diabetic improvements in surgical techniques reduced larval ischaemic foot ulcers (10); necrotic
ulcer- ation therapy to a ‘treatment of last resort’, reserved for the caused by repetitive footwear trauma of a
localised
most intractable wounds (5). foot metastasis (11); bilateral neuropathic foot
The emergence of antibiotic-resistant strains of ulceration (12) and chronic diabetic foot ulcers
bacteria such as methicillin resistant Staphylococcus (13–15). In all cases, the wounds were suc-
cessfully debrided of devitalised tissue and granula-
tion tissue developed rapidly.

ª 2007 The Authors

488 Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, March 2007, 61, 3, 488–493
promotes the healing process with relatively few side effects
(16–18). Larval therapy is also reported as being cost-
effective in comparison with conventional wound dressings
General benefits of larval therapy (19). An import- ant study investigated the efficacy and cost-
Anecdotal evidence has consistently suggested that larval effective- ness of larval therapy vs. hydrogel, and reported
therapy results in a reduction in wound pain and odour, and

that all wounds treated with larval therapy were success- fully
debrided following one application at a median cost of £78.64
(20). Treatment with hydrogel was proven to be less efficient
where it was noted that, following 1 month of treatment, one-
third of wounds still continued to require treatment. The
median cost of treatment for this group was £136.23.
However, the study involved only 12 patients (six within each
group) and thus lacked an adequate number of patients
required for large-scale trials to support the efficacy of
treatment. The use of larval therapy often resulted in quicker
healing, and a sub- sequent reduction of nursing time and
materials (19). Larval therapy has become available on
the drug tariff, thus further increasing its cost- effectiveness.
A further advantage of larval therapy is that, as larvae are
typically applied for 3 days, wounds are disturbed less
frequently than conventional dressings that require changing
every 1–2 days (21). In addi- tion to this, a further advantage
is that treatment can usually be carried out in outpatient and
community settings. A study at an outpatient wound clinic on
chronic wounds of varying aetiologies reported that using
larval therapy resulted in a 62% decrease in the need for
amputation (22).
Larval therapy and multi-resistance
The use of antibiotics to treat chronic wounds has lead to the
emergence of ‘resistant’ bacteria. Such strains possessed an
evolutionary advantage, and were able to increase their
population size through Darwinian selection (23). Despite the
pharmaceutical response in the form of other antibiotics such
as erythromycin and methicillin, further evolution of
microbial drug resistance has occurred at a rapid rate, and to
a point where antimicrobial resistance has become a major
threat to public health (24). The recent development of
vancomycin resistance has created an imperative need for
alternative methods of treating infection (25). The most
predominant microorganisms of concern include Escherichia
coli (E. coli), Pseudomonas aeruginosa and MRSA. MRSA
has become a frequent cause of nosocomial infec- tions and
‘epidemic’ strains have consequently
become the focus of much media attention in recent
years (26).
Larvae offer the benefit of eliminating bacteria
from the wound through ingestion and subsequent
degradation within their intestinal tract (27). They
also act to reduce bacterial activity through the
pro- duction of inhibitory secretions. Such actions
appear to hold true for MRSA as well as other
multi-resist- ant microorganisms, such as
Pseudomonas species. While the literature
suggests that larval therapy is less effective in
wounds infected with E. coli (28), this has since
been called into question. In vitro research
examining the ingestion by Lucidia sericata
larvae of E. coli (which produced a green
ª 2007 The Authors
Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, March 2007, 61, 3, 488–493
Larval therapy in wound management 489
fluorescent protein) showed a gradual decrease in
fluorescence from the anterior section of the larval
alimentary canal to its end, thus demonstrating a
reduction in the level of bacteria. It may be that a
greater quantity of larvae is required in vivo to
eradicate wounds of Gram negat- ive bacteria such
as E. coli (29).
Other evidence, while anecdotal, supports the
use of larval therapy against wound pathogens.
In a recent trial, larval therapy was used
successfully to treat chronic, MRSA-infected
wounds of five patients, including heel
ulceration (30). The authors remarked on a few
cases where MRSA infection was not successfully
eliminated, speculating that the treat- ment may
have been unsuccessful for reasons such as
insufficient application of larvae, or that therapy
may have been discontinued too early to allow
complete eradication of MRSA. Further research
reported the successful use of larval therapy in the
treatment of three wounds infected with MRSA,
however, the author failed to describe the types of
wound, their location and their duration (8).
Preliminary research has indicated that the puri-
fied secretions of sterile, aseptically raised L.
sericata larvae exhibited antibacterial activity
against MRSA in vitro; although activity was
found to be bacterio- static rather than bactericidal
(28). The authors remarked that the degree of
inhibition may have var- ied as a result of the
methods used for the collection of the secretions.
Subsequently, it was suggested that the study
undervalued the effects of larval secretions, as
they are produced continuously in vivo and thus
concentrations within the wound would be
greater. The authors proposed that a stronger
action against the growth of MRSA and other
multi-resistant microorganisms could therefore be
expected.
A recent study supported this research,
finding that secretions from L. sericata larvae
displayed potent antibacterial action against
MRSA (31). It was reported that the most
significant antibacterial activ- ity was from a
small fraction of larval secretion with a molecular
weight of <500 Da. However, antibacter- ial
activity was dependent on the selection of an
appropriate type of bioassay and optimal
conditions. The dilution of larval secretions was
believed to have influenced the findings (28).
Disadvantages of larval therapy
The most commonly mentioned
disadvantage of lar- val therapy is the
 Larval therapy in wound management 490

negative perception with which it is have been reported where larvae of Protophormia terraenovae and
regarded by both patients and not L. sericata were used (41). Alteration of the disinfection process
practitioners (5,18,32). Although the so- appeared to eliminate this problem, with no further cases of sepsis
called ‘yuk factor’ of its clinical occurring during the subsequent 12 months. The risk of cross-
appearance (Figure 1) has been frequently infection by escaped larvae may be greatly reduced through careful
reported in case studies, there is little dress- ing (42), although no occurrences have been docu- mented
evidence to suggest that patients refuse (43).
larval therapy when it is offered (33). The
use of ‘Biobags’ (Polymedics, Belgium), Mechanisms involved in larval therapy
which completely enclose the larvae
within a polyvinylalcohol membrane, has
become a popular method of improving
the application of this treat- ment (Figure
2). Larvae are able to feed freely
through the open cell polymer, but are less
visible to the squeamish patient or
practitioner
(34).
dressings, and treatment should be delayed until inflammation has
subsided (8). Several authors have proposed that skin surrounding
the wound should be protected using hydrocolloids or zinc paste to
prevent possible damage from powerful proteolytic enzymes within
larval secretions (33,38,39).
A case history has suggested larval therapy to be contraindicated
with fistulae, exposed vessels and wounds connecting to vital organs
(40). No occur- rences of allergic reaction were recorded, but blood-
stream infections (with Providencia stuartii and Candida albicans)
Appropriate education, perhaps incorporated into
the continuous professional development of the prac- Wound debridement
titioner, may prove useful in overcoming the scepti- Larvae feed on necrotic tissue, cellular debris and
cism and distaste of practitioners (8,35). Better exudate within the wound, thus debriding it of devi-
dissemination of information may also help address the talised tissue. In various randomised controlled clin-
problem of poor survival rates of larvae during ical trials, researchers noted that significantly more
wounds healed with frequent debridement, regardless of
treatment because of the lack of moisture (36).
the use of topical preparations (44,45). Debride- ment is
Pain has occasionally been reported by patients a critical factor in wound care, and is equally as
suffering from ischaemic wounds (9,37). The cause may important as pressure relief in facilitating wound
be the sharp mouth hooks and spicules with which healing (46).
larvae anchor themselves onto tissue. Contrac- tion of
necrotic tissue or pH changes within a wound may

ª 2007 The Authors

Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, March 2007, 61, 3, 488–493
 Larval therapy in wound management 491

affect pain receptors in proximal healthy tissue (37).

Occasionally inflammation of adjacent tissue may
also pose problems for adherence of

Figure 1 Photograph courtesy of Medical Photography Figure 2 Photograph courtesy of Medical Photography Department,
Belfast City Hospitals Trust. Larvae of Lucilia Department, United Hospitals Trust. Sterile LarvETM of sericata (approximately
15 mm in length) following Lucilia sericata prior to wound application removal from wound (post 3 days in contact)
The basic mechanism of larval debridement has been ant, thermally stable compound from larval
described by several researchers (47–49). The digestive secretions, which exhibited strong antibacterial activ-
juices secreted by larvae during the feeding process ity (31). Some antibacterial compounds isolated,
have been found to contain a variety of pro- teolytic such as phenylacetic acid and phenylacetaldehyde,
enzymes, including trypsin-like and chymot- rypsin-like are thought to be released by Proteus mirabilis, a
enzymes and collagenase (50). The enzymes selectively commensal species of bacteria found within the lar-
debride necrotic tissue, leaving viable tissue unharmed val alimentary canal (61). The symbiotic relationship
(1). Further research tested the effects of larval between larvae and particular bacterial species
secretions of Calliphora erythro- cephala on appears to facilitate wound disinfection, but further
experimental burns on rat skin, and research is required into the mechanism.

reported that the secretions had proteolytic proper- ties

in vitro and in vivo (51). peritrophic membrane, thus preventing recontamina- tion
(53).
Movement of larvae may stimulate the production of
Wound disinfection
serous exudate by the wound, thus increasing irri- gation and
Chronic wounds are frequently colonised and infec- ted with
removing bacteria (1), or wounds may be physically irrigated
a variety of wound flora, including Staphy- lococcus and
by larval secretions themselves (54). Other authors believe
Streptococcus species, P. aeruginosa and E. coli. Increased
the process to be more complex, and suggest that larval
bacterial load may impair healing, particularly if a wound
secretions play a greater role in wound disinfection (55).
becomes infected with anti- microbial resistant bacteria (as
Early research has shown that larval secretions contain a
discussed above). Dis- infection is therefore a critical
variety of alkaline components, including ammonium
component of wound healing.
bicarbonate, calcium, allantoin and urea that inhibit bacterial
The natural habitats of larvae include corpses and wounds,
growth (56–58). The subsequent increase in pH provides an
which typically contain a vast array of pathogenic
optimum environment for enzymatic activity, and also
microorganisms. In response to these conditions larvae are
renders the wound bed uninhabita- ble to many bacteria,
believed to have evolved several effective mechanisms for
hindering subsequent recoloni- sation (59).
removing bacteria. During feeding, larvae ingest bacteria
Disinfection may occur as a result of the release of
within devitalised tis- sue thus physically removing
compounds in larval secretions in conjunction with the
microorganisms (52). Research has suggested that any
digestion of devitalised tissue (60). It has been proposed that
bacteria which are not destroyed within the acidic alimentary
larvae release antimicrobial substances as part of an innate
canal are contained within a tubular structure known as the
response to high levels of bac- teria (3). In vitro research
isolated a protease resist-

ª 2007 The Authors

Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, March 2007, 61, 3, 488–493
 Larval therapy in wound management 492

Promotion of wound healing secretion of allantoin, ammo- nium bicarbonate

Research has consisted of small-scale clinical
trials and in vitro investigations of the properties
of larval secretions. Surprisingly, as it has no
benefit to the larvae, therapy appears to
encourage the formation of granulation tissue in
the wound bed and acceler- ate wound healing
(9,62).
In a comparative study of chronic wounds of
mul- tiple aetiologies, it was reported that all
wounds healed following 4 weeks of treatment
with larval therapy, whereas necrotic tissue was
still present on the surface of conventionally
treated wounds follow- ing 5 weeks (63). This
finding was in agreement with earlier work by the
author who compared the healing rates of pressure
ulcers treated with either conven- tional dressings
or larval therapy (64). Several case studies
involving chronic leg ulcers have also recor- ded
the development of granulation tissue within the
wound bed (18,65,66). During an in vivo study, a
single application of larvae was applied to
chronic leg ulcers (n ¼ 30) of mixed aetiology
(67). The wounds were assessed subjectively,
using a wound scoring system, and objectively,
using remittance spectroscopy. Following
treatment with larvae, remit- tance was greatly
reduced because of an increased quantity of
granulation tissue within the wound bed. The
authors concluded that larval secretions had a
positive effect on wound healing because of the
development of granulation tissue and increased
tis- sue oxygenation.
As discussed earlier, the constant movement of
lar- vae within the wound is believed to
mechanically sti- mulate the wound bed (68).
However, use of ‘Biobags’ that inhibit
mechanical stimulation has also resulted in
improved healing, suggesting that factors other
than mechanical stimulation are involved
(34,69).
The properties of substances within larval
secre- tions, described as a healing ‘active
principle’ (56,58), have been the subject of
subsequent research and suggested that the
and urea provide an optimal growth environment
for cells involved in wound healing by acting as
growth factors (70,71). The alka-
suggested that the resultant tissue proliferation within the wound
stimulated by the release of growth factors may provide larvae with
better nourishment.
Further research investigated the in vitro effects of larval
secretions on human dermal neonatal fibro- blast cells and reported
that the presence of secre- tions resulted in a reduction in fibroblast
adhesion to fibronectin and collagen (which are constituents of the
extracellular matrix modification) (74). The authors suggested that
this may be due to proteolytic activity of larval secretions altering
the structure of the extracellular matrix. They postulated that this
behavioural modification within the wound may pro- mote the
formation of new tissue. This supported earlier work proposing that
the activity of trypsin- like and chymotrypsin-like proteinases
strongly influ- enced the remodelling of the extracellular matrix
(62).
Conclusion
From the literature reviewed it can be
noted that as a treatment, larval therapy
offers numerous advan- tages including
rapid wound debridement and elim-
ination of infection, control of pain and
odour, and the promotion of wound
healing. Use of larval ther- apy has
resulted in few side effects, and has
reduced the need for amputation (22). It is
also apparent that the treatment also offers
an efficient alternative to antibiotic
therapy for the treatment of wounds con-
taminated with a variety of wound
pathogens, inclu- ding MRSA and E. coli.
Having been largely superseded by
antibiotics, larval therapy has reemerged
as one of the current strategies for target-
ing microbial resistance.
It is apparent that the literature
consists mainly of case studies into the
applications of larval therapy. Large-scale
clinical trials are required to further
examine the efficacy of the process and its

line nature of these substances has been reported to wound processes to promote healing. Whilst not suitable have a
role in the promotion of healing by altering the for all wounds, larval therapy should no lon- ger be pH of the
wound (72). viewed as a treatment of last resort.
In vitro research noted that whilst larval secretions stimulated
growth of human fibroblast growth, the effect
Acknowledgements
was increased when combined with epidermal growth factor (73). The results indicated that secre- tions may
Thanks to Ms J. Cundell, Lecturer/Practitioner, enhance healing through interaction with compounds University of
ª 2007 The Authors
Ulster/Belfast
Journal compilation City Hospitals
ª 2007 Blackwell Publishing Trust,
Ltd Int Jreleased byMarch
Clin Pract, the wound. This
2007, 61, research demonstrated for N. Ireland for accessing
3, 488–493
and providing photographs the first time that the insect moult- ing hormone, 20- from Medical Photography
departments.
hydroxyecdysone, stimulates fibro- blast growth. It was

effects on healing times. Overall, larval
therapy facilitates the efficient and
selective debridement of devitalised tis-
sue. The treatment has the added benefit
of being bactericidal whilst functioning
in harmony with
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Paper received July 2006, accepted September 2006

ª 2007 The Authors

Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, March 2007, 61, 3, 488–493