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doi: 10.1097/NHH.0000000000000044

Bedbugs: What Nurses Need to Know From treating lesions to treating the home, management of an infestation is multifaceted.

Barnes, Emily R. DNP, RN; Murray, Billie S. MSN, RN

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Author Information

Emily R. Barnes and Billie S. Murray are Clinical Assistant Professors at West Virginia University School of Nursing in Morgantown.

Contact author, Emily R. Barnes:

The authors have disclosed no potential conflicts of interest, financial or otherwise.

This article originally appeared in American Journal of Nursing 2013;113(10):58–62.

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I t could happen to anyone. A family is vacationing, and after checking into a hotel the kids and their mother go to bed. A short while later, the husband approaches the bed where his wife is sleeping; he notices something moving on the white sheet near her head. It's an insect. He catches it, places it on a tissue, and logs onto his computer to try to identify it. Soon he realizes it's a bedbug, wakes his wife and children, and calls the front desk. The hotel's pest manager comes up and confirms it: there's a bedbug infestation in the room, and the hotel moves the family to another part of the building.

It could happen to anyone, and it happened to one of us (ERB). Soon after, the two of us decided to find out how to care for people exposed to bedbugs. We learned that such experiences are increasingly common. Cimex lectularius, the bedbug, has been a pest to humans, other mammals, and birds for thousands of years. Use of the insecticide dichlorodiphenyltrichloroethane (DDT) virtually eradicated bedbugs in developed countries in the late 1940s, but by the 1950s the bugs were showing resistance to the chemical, which was banned from use in the United States by the 1970s. With the decline in use of DDT, pyrethroid insecticides became the primary chemical method of controlling bedbugs,1 which have developed genetic adaptations to these as well. Such genetic adaptations prevent or slow the transport of the toxin to the insects' neurons, the target site, and often result in cross-resistance to other pesticides, contributing to the pests' resilience.1

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This pesticide resistance, increases in human immigration and global travel, and changes in pest-control practices have contributed to the rising incidence of bedbug infestations.2,3 In a 2013 survey of 251 U.S. pest-control professionals, 70% reported an increase in bedbug infestations; only 3% reported a decrease.4 Despite their near ubiquity, bedbugs are stigmatizing, and stigma can contribute to delays in extermination.5 Eradication is made even more difficult by the need for more effective pesticides, by the public's general lack of awareness on prevention, and by unease about treating homes with chemicals.6 And the bedbug is a particularly hardy parasite: it can live without feeding for six months.7

Infestations have historically been found in hotels and apartment buildings, usually where people sleep, and more often in urban areas than in rural ones. In recent years, bedbugs have also infested single-family homes, health care facilities, college dormitories, office buildings, schools and day-care centers, retail stores, libraries, churches, theaters, museums, hostels, homeless shelters, military barracks, laundries, used-furniture outlets, and trains and airplanes.3–5,8 Bedbug infestations reported to pest-control services have decreased slightly in hotels from 2011 but have increased in libraries.4 In New York City, even the popular clothing stores Victoria's Secret and Abercrombie and Fitch have reported infestations.9

The adult bedbug is 4 to 5 millimeters in length and red-brown in color. Bedbugs are nocturnal parasites that live in groups, often in the crevices of mattresses and cushions. They can also be found under peeling paint, loose wallpaper, carpeting at baseboards, and light-switch plates or electrical outlets. Over a lifetime, the adult female bedbug lays about 150 to 500 eggs7—about one to seven per day for 10 days after feeding—80% or more of which mature to adulthood.10 The female needs a blood meal in order to develop eggs; blood meals are also necessary for bedbug larvae to progress through each of the five stages of the growth cycle. But, as with adult bedbugs, larvae can subsist for several months without a blood meal. (For more on the bedbug's life cycle and mating habits, including “traumatic insemination,” go to

Bedbugs are attracted to the carbon dioxide people exhale while at rest. During a feeding, which lasts for two to five minutes, a bedbug injects into its host a salivary protein, nitrophorin, to induce vasodilation. This protein may be responsible for an immunologic response in some people.11

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Is That a Bedbug Bite or Something Else?

There is no evidence that bedbugs transmit disease, and their bites are painless and may initially go unnoticed. If bites are noted after a person wakes, they are typically found on skin that was exposed during sleep, such as the head, neck, shoulder, arms, and legs.2,8,12 In the case of a severe infestation, lesions may be found on covered areas of the body as well.12

A person's reaction to bedbug bites can range in severity. With repeated exposure, the host becomes sensitized and the reaction may be more pronounced.6,13 As exposure increases, the time between bite and cutaneous reaction decreases.6 Rarely, systemic reactions such as asthma and anaphylaxis can occur.6

Diagnosis requires taking a thorough history, one that includes questions on recent travel, houseguests, any contact with others who travel frequently or have visited infested areas, and the use of previously owned furniture. Nurses should ask about the primary symptoms and location of lesions, as well as about any new or changed prescription or over-the-counter medications, new household cleaners or laundry detergents, dietary changes, exposure to animals, and attendance at outdoor events.

Differential diagnoses include scabies, bites from other parasitic arthropods such as fleas or mites, vesicular disorders such as dermatitis herpetiformis, or delusional parasitosis.2 Because the signs and symptoms of bedbug bites can be so wide ranging, the lesions have been misdiagnosed as evidence of drug reactions, food allergies, chicken pox, erythema multiforme, and contact dermatitis.8,12,14

Scabies lesions are typically found in warm, moist parts of the body such as the axilla, groin, and waist, and burrows (tiny tracks in the skin) are usually present. A spider bite often produces a single, sometimes bullous lesion that's painful and swollen. Lesions from flea bites can be found over the entire body but more often on the lower body. Dermatitis herpetiformis, a condition caused by gluten allergy, presents as pruritic, papular, or bullous lesions, typically on the scalp, shoulders, buttocks, elbows, and knees. Drug eruption may manifest in a variety of ways, including fixed drug reactions, Stevens–Johnson syndrome, and toxic epidermal necrolysis. Chicken pox usually appears as itchy, red papules that progress to vesicles or pustules and most often affects young children; prodromal and systemic symptoms are often present, including fever, headache, or other flu-like symptoms. Erythema multiforme, a hypersensitivity reaction resulting from an infection or a medication, presents with classic, target-like lesions and affects at least one mucous membrane.

Physical examination. Bedbug bites appear as 2-to-5-millimeter, pruritic, erythematous, maculopapular lesions with a central punctum.2,6 Lesions will usually resolve in a week if they are not abraded.6 Bedbug bites may also appear as pruritic wheals, papules, diffuse urticaria, or bullous rashes.6 Secondary infections may cause folliculitis, cellulitis, or impetiginous lesions.6 One case of a bedbug feeding on the tympanic membrane, leading to otitis, has been reported.15 Therefore, it may be prudent to examine body orifices for the presence of bedbugs.

Laboratory workup. Diagnosis is based primarily on history and clinical presentation, and so a laboratory workup is not typically indicated. In cases of unclear history and clinical signs and symptoms, biopsy is an option. Histologic findings from bedbug bites are consistent with those of other arthropod bites.16 If the lesions appear infected, bacterial culture and sensitivity testing is appropriate. In the case of severe, prolonged infestation, anemia is a risk and a complete blood count is warranted.13,17

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Treating the Patient and the Home

Treatment of the lesions is typically supportive. Over-the-counter or prescription antipruritic agents or intermediate-potency corticosteroids may be used for itchy lesions.6,14 If a secondary infection occurs, topical or systemic antibiotics may be necessary.3,6 For rare systemic reactions, patients should be referred to the ED for treatment that may include intramuscular epinephrine, antihistamines, or corticosteroids.6 To limit further exposure while a patient's home is being treated for an infestation, permethrin 5% cream or N,N-diethyl-meta-toluamide (DEET) 40% may be applied at bedtime.14 Both must be used as directed to limit the risk of adverse effects or toxicity.

Bullous reactions require more aggressive treatment measures; such lesions indicate a high sensitivity to bedbug bites.11 The treatment of choice is a combination of a high-potency topical corticosteroid and an oral antihistamine. For diffuse bullous lesions, oral corticosteroids should be considered. Patients with bullous reactions should be screened for symptoms of systemic vasculitis. Referral to a dermatologist may also be considered.

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Treatment of the home or other environment by a pest-control service is essential to eradicating and monitoring infestations.2,3,5,8,14 When possible, an exterminator with experience in eradicating bedbugs should use at least three different pesticides and return for a treatment three weeks later.14 We found no studies showing the comparative effectiveness of commonly used pesticides.

Given the proliferation of bedbugs and their resistance to chemical treatments, a multifaceted approach is advised.18,19 The Centers for Disease Control and Prevention (CDC) and the Environmental Protection Agency issued a joint statement in 2010 advocating the use of integrated pest management (IPM) in bedbug control (go to IPM includes using monitoring devices, keeping affected areas clean and free of clutter, sealing cracks where the bugs can hide, and applying chemical and nonchemical treatments known to be effective. IPM requires cooperation among building residents and owners, pest-control professionals, and regulatory officials to prevent, identify, and treat infestations.19 The so-called dust-band treatment has been shown to be as effective as IPM; it includes wrapping furniture legs with fabric treated with pesticide dust, thus exposing the bedbugs to the chemical as they travel across the furniture, a method that also reduces the amount of pesticide used.20

All people are at risk for bedbug exposure. But social determinants of health such as poverty can affect the likelihood of infestation. Vulnerable populations may not be able to afford costly pest-management services.21,22 People living in poverty may dwell in apartment buildings in which bedbugs move easily from one unit to the next.21 For impoverished patients with bedbug infestations, the local health department and office of the U.S. Department of Housing and Urban Development may help in obtaining needed resources.18 Tenants of an infested building might consider sharing the cost of professional extermination.

Not only are most over-the-counter pesticides and homemade treatments ineffective,18 they can also be dangerous, and all pesticides must be used with caution. To prevent overexposure to toxic chemicals, nurses should caution patients against nonprofessional eradication measures.14 Only registered pesticides marked for indoor use against bedbugs should be used to treat infestations.18 If pesticides registered for outdoor use are used indoors, or if indoor pesticides are used in greater-than-directed quantities, serious adverse health effects may occur.18

There have been reports of property damage, illness, and death related to nonprofessional attempts at eradicating bedbugs. In New Jersey, a man burned part of his home trying to get rid of the pests with a space heater, a hair dryer, and a heat gun.23 The CDC has reported that between 2003 and 2010, there were 111 cases of acute illness (including one death), 39% of which were associated with nonprofessional application of pesticides for bedbug control.24 Other reported symptoms from pesticide exposure during bedbug treatment include headache, dizziness, upper-respiratory pain and irritation, dyspnea, and nausea and vomiting.24 In November 2011, the CDC issued a public health advisory cautioning against the misuse of pesticides and encouraging the use of IPM in bedbug eradication.25

Nonchemical approaches to eradication include applying diatomaceous earth, scrubbing surfaces with a stiff brush to remove eggs, vacuuming, washing linens in hot water (at least 120°F), placing items in a clothes dryer for 30 minutes at high heat, and using commercial steamers.14,18,19,26 Szyndler and colleagues have reported on a new, nonchemical approach to entrapping bedbugs: a synthetic material that mimics the surface of bean leaves, with tiny projections called trichomes that impale the legs of the bedbugs as they cross the surface.27 Infested furniture can be cleaned and treated instead of thrown out; throwing out furniture can contribute to the spread of bedbugs.26 Furniture that cannot be treated should be marked as infested and destroyed to prevent further spread.19 Also, plastic encasements on mattresses and box springs can protect them from future infestation.6

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Treatment of psychosocial effects should also be considered when a patient reports an infestation. Patients may suffer from lowered self-esteem or feel stigmatized from visible bites, worry about the cost of eradication, or exhibit delusions of a lingering sensation of bugs after their eradication.8 Other psychosocial effects include nightmares, flashbacks, insomnia, anxiety, depression, and exacerbation of existing psychiatric disorders; one case of suicide resulting from bedbug infestation has been reported.28 Nurses and other health care providers may contribute to patients' feelings of stigma and isolation by avoiding them out of their own fears of infestation; Laliberté and colleagues recommend that facilities institute policies ensuring that “patients receive the care to which they are entitled” and that health care providers take proactive steps to avoid the spread of an infestation.22

The emotional and psychological stress of bedbug bites or infestation has been reported to meet the diagnostic criteria of posttraumatic stress disorder.29 Nurses should therefore screen all affected patients for psychological consequences of an infestation.14,29 Screening tools for depression and anxiety are widely available, such as the nine-item Patient Health Questionnaire (PHQ-9) and the seven-item Generalized Anxiety Disorder scale (GAD-7). Treatment for the psychosocial consequences of bedbug infestations will vary according to the patient's symptoms, but it may include pharmacotherapy or referral for counseling or behavioral medicine. If a patient is exhibiting severe psychosocial distress, such as suicidal ideation, immediate referral is required for her or his safety.

Prevention of infestation in the health care setting. Nurses should be aware of the spread of bedbugs in health care facilities when caring for patients with an infestation. Although bedbugs do not typically inhabit the host, nurses should be alert to the possibility of live infestation on patients or their belongings. If live bedbugs are found, the nurse should contact the facility's environmental services department and isolate the area. Regular inspection of the facility for droppings, live bugs, or shed exoskeletons should be a part of routine maintenance.30 Furniture in health care facilities should be made of plastic and metal; such materials impede the bugs' travel.19 Administrators should consider implementing policies to guide staff in handling parasitic infestations that include timely recognition, communication to appropriate personnel, and treatment of both the room and the patient's belongings.30,31

Patient education is an important element of the treatment plan. There is no evidence that bedbugs serve as a vector for blood-borne disease,6,14 and informing patients of this may help to alleviate some of their distress.

Patients can be educated on preventative measures. A traveler should store luggage on a table or dresser, not on the hotel-room floor. Beds and surrounding areas should be inspected, especially mattress cords, box springs, and the back of headboards. Signs of bedbugs include dark specks along mattress seams from excrement, shed exoskeletons, and small bloody smears on sheets from accidental crushing of engorged bugs. Using white linens can help in finding signs of bedbugs, as can waking in the early morning when bedbugs are most active.14 Early detection and ongoing monitoring of eradication efforts are crucial to curbing an infestation. Monitoring systems available commercially have been found to be as effective as visual inspection.32 Passive monitoring involves the use of traps without an attractant; active monitoring involves an attractant such as carbon dioxide, heat, or chemicals.32,33 Wang and colleagues compared the effectiveness of a homemade active-monitoring system (using dry ice, an inverted cat feeder, and an insulated jug) with commercially available systems and found the homemade system to be more effective and cost-efficient, although dry ice presents a risk of injury.32

Follow-up. In most cases, treatment of lesions from bedbug bites is supportive and no follow-up is required. However, if the infestation is not eradicated, new lesions will develop. Hence, a focus on eradication efforts is an essential element of the treatment plan. Patients should be encouraged to follow up if signs or symptoms of a secondary infection or systemic symptoms occur. Patients experiencing psychological consequences should be monitored regularly, as determined by symptom severity or medication requirements.

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