Beyond Myiasis: Understanding Environmental Factors, Maggots, and Infection Risks in Xylazine-Associated Wounds.

The emergence of xylazine-associated wounds, highlighted by case reports from Philadelphia in 2022, has been linked to the use of this veterinary sedative as an adulterant in the unregulated drug supply and has brought renewed attention to the challenges of complex wound management, particularly in vulnerable populations. Among these challenges are unusual infectious complications, including cases of larva-associated infections such as  bacteremia in maggot-colonized wounds, raising critical questions about the role of environmental exposure, wound neglect, and the presence of maggots. Clinicians must recognize that rare infections often arise not from the drug itself but from environmental exposure and delayed wound care. Furthermore, it is essential to distinguish between uncontrolled myiasis (spontaneous, unsanitary maggot infestation) and the therapeutic application of sterile  larvae through medically supervised larval therapy. Building on historical observations and contemporary wound care literature, we explore how larval therapy offers a precise, cost-effective method for wound debridement, particularly valuable in situations in which definitive surgical care is delayed or unfeasible. As clinicians confront the rising burden of xylazine-related wounds, a nuanced understanding of environmental infectious risks and biosurgical interventions can expand the surgeon's wound care armamentarium and improve outcomes not only for patients with drug-induced wounds but also for individuals with chronic wounds.