Characteristics of Bed Bug Infested Patients in the Emergency Department

Bed Bug Infestation: An Updated Review

In the past decade, there has been a global resurgence of bed bug infestations, especially in developed countries. Proper awareness and identification of bed bug infestations are essential to guide treatment and eradication. The purpose of this article is to familiarize physicians with bed bug bites so that they can effectively diagnose, treat, and address questions about bed bug bites and infestations. Bed bug bites are often painless. Typical reactions include pruritic, erythematous maculopapules occurring in clusters or in a linear or curvilinear distribution in exposed areas of the body. A small red punctum may be visualized at the center of the bite mark. Lesions that appear three in a row and papules on the upper eyelid associated with erythema and edema are highly suggestive of bites from bed bugs. Exaggerated local reactions such as vesicles, urticarial wheals, urticarial perilesional plaques, diffuse urticaria, bullae, and nodules may occur in previously sensitized individuals. Reactions to bed bug bites are self-limited. As such, treatment is mainly symptomatic. Topical pramoxine and oral antihistamines can be used to alleviate pruritus. Topical corticosteroids can be used for significant eruptions to control inflammation and pruritus, and to hasten resolution of the lesions. Integrated pest management, an approach for the eradication of bed bugs, includes monitoring devices (active monitors include the use of heat or carbon dioxide attractants and passive monitors include the use of sticky pads for trapping), and judicious use of nonchemical and chemical treatments known to be effective. Nonchemical interventions include keeping affected areas clean and free of clutter, vacuuming, washing linens with hot water, caulking wall holes and cracks where bugs can hide, proper disposal of highly infested items, and placement of bed bug traps/interceptors at the base of beds and furniture. Chemical interventions involve the use of insecticides such as synthetic pyrethroids, silicates, insect growth disruptors, carbamates, organophosphates, neonicotinoids, diethyl-meta-toluamide, chlorfenapyr, fipronil and plant essential oils. Insecticides should be used with caution to prevent over-exposure and toxicity (in particular, cardiovascular and neurologic toxicity), especially if there are young children around. It is important to note that multiple mechanisms of insecticide resistance exist and as such, chemical treatment should only be undertaken by trained professionals who understand the current literature on resistance. Both nonchemical and chemical technologies should be combined for optimal results. Bed bug infestations may cause diverse dermal reactions, stigmatization, poor self-esteem, emotional stress, anxiety, significant adverse effect on quality of life, and substantial socioeconomic burden to society. As such, their rapid detection and eradication are of paramount importance. Consultation with a professional exterminator is recommended to fully eradicate an infestation.

A metatranscriptomic evaluation of viruses in field-collected bed bugs

Cimex lectularius, known as the common bed bug, is a widespread hematophagous human ectoparasite and urban pest that is not known to be a vector of any human infectious disease agents. However, few studies in the era of molecular biology have profiled the microorganisms harbored by field populations of bed bugs. The objective of this study was to examine the viruses present in a large sampling of common bed bugs and related bat bugs (Cimex pipistrelle). RNA sequencing was undertaken on an international sampling of > 500 field-collected bugs, and multiple workflows were used to assemble contigs and query these against reference nucleotide databases to identify viral genomes. Shuangao bed bug virus 2, an uncharacterized rhabdovirus previously discovered in Cimex hemipterus from China, was found in several bed bug pools from the USA and Europe, as well as in C. pipistrelle, suggesting that this virus is common among bed bug populations. In addition, Shuangao bed bug virus 1 was detected in a bed bug pool from China, and sequences matching Enterobacteria phage P7 were found in all bed bug pools, indicating the ubiquitous presence of phage-derived elements in the genome of the bed bug or its enterobacterial symbiont. However, viral diversity was low in bed bugs in our study, as no other viral genomes were detected with significant coverage. These results provide evidence against frequent virus infection in bed bugs. Nonetheless, our investigation had several important limitations, and additional studies should be conducted to better understand the prevalence and composition of viruses in bed bugs. Most notably, our study largely focused on insects from urban areas in industrialized nations, thus likely missing infrequent virus infections and those that could occur in rural or tropical environments or developing nations.

Analysis of Patients With Bed Bugs in the Emergency Department

The objective was to evaluate the clinical characteristics, triage information, diagnostic evaluation, and disposition for emergency department patients with and without bed bug infestation. A retrospective case-control study of patients with and without bed bugs was performed from February 1, 2011, through February 1, 2017. Cases (n = 332) and controls (n = 4,952) were matched by age, sex, and emergency department location. Patient characteristics and clinical information were compared between groups. On univariable and multivariable analysis, patients with bed bugs had higher heart rate, lower systolic blood pressure, higher pain scores, and more frequent tobacco use in the past year. They were also more likely to screen positive in triage for an unsafe home; require an abuse consultation; be diagnosed in the emergency department or inpatient setting with malnutrition, marasmus, and/or cachexia; have more emergency department and hospital visits; and have longer hospital encounter lengths of stay (all p ≤ 0.02). On univariable analysis, patients with bed bugs were also more likely than uninfested controls to be single, be Black, come to the emergency department from home, arrive to the emergency department by ambulance, and not be discharged back to their homes from the hospital.

Investigating the association of bed bugs with infectious diseases: A retrospective case-control study

Bed bugs are common urban pests. Unlike many other blood-feeding human ectoparasites, bed bugs are not known to be vectors of human infectious diseases, but clinical and epidemiological studies to directly interrogate this link have been limited. Here, we aimed to determine whether bed bugs were associated with infectious diseases in a set of infested patients presenting to emergency departments (ED) in the greater Cleveland, OH area. We performed a retrospective case-control study involving 332 ED patients with bed bugs and 4,952 control patients, seen from February 1, 2011, through February 1, 2017. Cases and controls were matched by age, sex, and the presenting ED. Additionally, data were adjusted for ≥20 sociodemographic variables, triage data, and comorbidities in multivariable regression analyses. Seventeen laboratory values, ten different ED and inpatient diagnoses, chest radiographs, infectious disease consults, and blood cultures were examined. The odds of bed bug infestation were significantly higher for patients that had positive blood cultures, had blood cultures growing coagulase-negative Staphylococcus, were diagnosed with pneumonia, were diagnosed with cellulitis, received an infectious disease consult, received a chest radiograph, and had higher percentages of eosinophils in the blood (P < .05 for all). Additional investigations are needed to determine whether bed bugs directly contribute to disease by transmitting causative agents, whether bed bug exposure contributes secondarily contributes to infections, or whether these associations are better explained by other environmental and social determinants of health.

Respiratory diseases in patients with bed bugs

INTRODUCTION

Some arthropods such as cockroaches can exacerbate asthma, but it is unknown is this is true of bed bugs.

OBJECTIVES

The objective of this work is to determine if bronchospastic diseases like asthma and chronic obstructive pulmonary disease (COPD) would be higher for ED patients who have bed bug infestation compared with patients who do not have bed bug infestation.

METHODS

A case-control study was performed with 332 adult emergency department (ED) patients with bed bug infestation and 4952 without infestation. Univariable and multivariable regression analysis was performed.

RESULTS AND CONCLUSION

Patients with bed bug infestation were not more likely to have a past history of or an ED diagnosis of asthma or chronic obstructive pulmonary disease (COPD). However, bed bug infested patients were significantly more likely to undergo chest radiography, be admitted to the hospital, and receive albuterol in the ED (P < 0.05). Infested patients receiving albuterol in the ED were more likely to be admitted to the hospital compared with uninfested patients receiving albuterol (P < 0.001). Patients with an ED or inpatient diagnosis of asthma or COPD and bed bugs (compared with those without bed bugs) had significantly more ED visits during the study (P < 0.03). Bed bug infestations may be associated with respiratory pathology, which requires further investigation.

Associations Between Bed Bugs and Mental Illness Among Emergency Department Patients

Background Bed bugs are common urban pests associated with stress, anxiety, depression, and some reports of suicidality. The emergency department (ED) treats patients with both acute mental illness and bed bug infestations. There have been few studies examining associations between bed bug infestations and mental illness. Methods A case-control study involving 332 adult ED patients infested with bed bugs and 4,952 uninfested control patients matched on sex, age (±1 year at the time of the ED visit), and the specific ED was completed. All clinic encounters occurred in northeast Ohio between February 1, 2011, and February 1, 2017, from a single health system. Univariable and multivariable regression analysis looked for associations between bed bug infestation and different psychiatric diagnoses and medications. Results Bed bug infested patients were more likely than uninfested patients to screen positive for an unsafe home and needing an abuse consult at ED triage (P≤.03 for both). ED psychiatric evaluations were not significantly more common among those with (2.4%) and without (1.3%) bed bugs (P=.14). Bed bug infested patients were significantly more likely to have an ED or inpatient diagnosis of alcohol abuse and psychosis (P≤.03 for both), but not for depression or suicidality. On univariable analysis, among ED patients not admitted to the hospital, bed bug infested patients were more likely to be diagnosed with psychosis or schizophrenia/schizoaffective disease (P≤.02) than uninfested patients. Among ED patients that received an ED or inpatient psychiatric evaluation and were admitted to the hospital, bed bug infested patients were significantly less likely to be diagnosed with depression and suicidality (P≤.03 for both). However, they were not significantly more likely to have insomnia or anxiety. Discussion Among ED patients, bed bug infestations were not associated with an ED or inpatient diagnosis of depression or suicidality. On univariable analysis, some mental health diagnoses such as anxiety and insomnia were more common among ED patients with bed bugs, but these associations were no longer significant on multivariable analysis. These associations likely reflect the complex relationships between socioeconomic factors, health disparities, mental illness, and having a bed bug infestation.

Association between bed bugs and allergic reactions

AIMS

To evaluate whether bed bugs are associated with allergic reactions in patients seen in the emergency department (ED).

METHODS AND RESULTS

This retrospective study included data from 9 EDs in Ohio between February 2011 and February 2017. The study comprised 332 patients with bed bug infestation matched 1:15 with 4952 control patients without bed bugs on the basis of age, sex and the presenting ED. Compared with uninfested patients, patients infested with bed bugs were more likely to have an ED or inpatient diagnosis of pruritus, hives or urticaria (odds ratio [OR], 9.12 [95% CI, 3.41-24.42]) and to be treated in the ED with an antihistamine (OR, 3.20 [95% CI, 1.87-5.50]) or albuterol (OR, 1.59 [95% CI, 1.07-2.36]) (P ≤ .02 for all). There were no significant differences in the rates of anaphylaxis and angioedema diagnosed in patients with and without bed bugs, which occurred in <1% in both groups.

CONCLUSION

Bed bug-infested patients are more likely to be diagnosed and treated for itchy cutaneous rashes, but are not clearly associated with more severe allergic reactions.

Bed bugs are associated with anemia

INTRODUCTION

Bed bugs are hematophagous insects that can be problematic in some urban emergency departments. The objective was to determine if red blood cell (RBC) and coagulation indices of bed bug-infested emergency department (ED) patients differed from those of noninfested control patients.

METHODS

A chart review from a single health system was performed for ED patients between February 1, 2011, and February 1, 2017. Bed bug-infested patients were matched to noninfested control patients on the basis of age, sex, and the presenting ED. Variables were analyzed with the t-test and Pearson χ² test and were modeled with multivariable logistic regression.

RESULTS

The study had 332 bed bug-infested patients and 4952 controls. Infested patients had lower hemoglobin (11.7 g/dL vs 12.8 g/dL), hematocrit (35.0% vs 37.9%), RBC counts (4.1 × 10⁹/L vs 4.4 × 10⁹/L), mean corpuscular volume (86.0 vs 87.5 fL/cell), and mean corpuscular hemoglobin concentrations (33.2 vs 33.7 g/dL) and higher RBC distribution width-coefficient of variation (RDW-CV) (15.2% vs 14.2%) than noninfested patients (all P ≤ .003). Infested patients were more likely to be anemic (59.5% vs 36.9%) and to have severe anemia (4.4% vs 0.7%) (P < .001 for both). Blood transfusions were more common in those with bed bugs (5.1%) than those without bed bugs (2.3%) (P < .001).

CONCLUSION

Bed bug infestated patients in the ED are associated with anemia.

Knowledge, Experience, and Concerns Regarding Bed Bugs Among Emergency Medical Service Providers

Introduction

Bed bugs are commonly encountered by emergency medical service (EMS) providers. The objective of this study was to determine the frequency with which EMS providers encountered bed bugs, assess their knowledge about bed bugs, and analyze the actions they take after finding bed bugs.

Methods

We anonymously surveyed 407 EMS providers from 180 EMS agencies in northeast Ohio between September 1, 2018, through March 31, 2019.

Results

Among the providers surveyed, 21% (n = 84) of the EMS providers reported seeing bed bugs at least monthly, and 6% (n = 24) reported seeing bed bugs at least weekly. Being younger, male, and working in an urban environment (vs. rural) were associated with EMS providers reporting more frequent bed bug encounters (p: ≤.05). The mean level of concern for encountering bed bugs among EMS providers was 3.54 (SD: 1.15; scale: 1 = no concern, 5 = very concerned). Among the EMS providers who reported seeing bed bugs at least monthly, 30% took the affected EMS stretcher out of service when they encounter a bed bug, 43% took the EMS rig out of service, 83% cleaned the EMS stretcher with a disinfectant, and 88% notified the ED that their patient has bed bugs. EMS providers scored poorly (mean: 69% correct responses) in a seven-question assessment of basic bed bug biology and public health.

Conclusion

Based on our findings, we concluded that EMS knowledge and behavior related to bed bugs are suboptimal.

A Preliminary Report Showing Spinosad and Fluralaner Are Able to Incapacitate Cimex lectularius L., the Common Bed Bug

Cimex lectularius L., the common bed bug, is a hematophagous human ectoparasite. The veterinary drugs, spinosad and fluralaner, were studied for their ability to incapacitate C. lectularius when administered in a blood meal using an artificial feeding system under laboratory conditions. Tested drug doses were based on the reported peak blood levels in animals given the drugs. Spinosad at doses 1,000 ng/mL or higher resulted in 75% or greater bed bug incapacitation (defined as death or immobility). Fluralaner at doses 500 ng/mL or higher had 100% bed bug incapacitation. Both drugs were significantly more effective than controls at these doses (P < 0.001).

The Benefit of a Single Oral Dose of Ivermectin in Humans: The Adverse Effects on Cimex lectularius L. Populations and Fecundity

Objective

To measure the population size and fecundity of the common bed bug Cimex lectularius L. (C. lectularius) after feeding it with the blood obtained from human subjects who have consumed a single dose of ivermectin.

Methods 

Serial blood samples were obtained from two human subjects at hour 0 (control) and 4-96 hours after they received a single 0.2 mg/kg dose of ivermectin. The blood samples were then fed to 2,273 bed bugs. Bed bug incapacitation rates, fecundity, and population sizes were recorded over a 54-day period. Whole blood ivermectin levels were measured in the human subjects and the insects.

Results 

The fold change in the size of the control group population over the course of the experiment was found to be 2.16. This was significantly greater (p: <.001) than for all the post-ivermectin feeding groups (range: -11.04-1.43). Two weeks after the experiment, the number of eggs laid per live adult female bed bug per day was 10.74 for controls, which was significantly different (p: <0.001) compared to all the post-ivermectin feeding groups (range: 0-4.28).

Conclusions 

There were significant reductions in C. lectularius population size and fecundity in insects that fed on blood obtained from human study subjects up to 96 hours after they have consumed a single oral dose of ivermectin.

Cimicosis in Persons Previously Fed Upon by Bed Bugs

Introduction

Bed bug infestations have risen dramatically in many industrialized nations in recent decades. Most people fed upon by bed bugs will develop a pruritic rash although the frequency with which this occurs is not definitively known and may depend on host factors including the duration of the infestation.

Methods

Surveys were completed from 706 emergency department (ED) patients in Cleveland, OH about their current and past exposure with bed bugs. Subjects were asked about any post-bed bug feeding rashes that developed.

Results

There were 24% (169/698) of subjects reporting either a current or past home bed bug infestation, with 37% (253/698) reporting they had previously been fed upon by a bed bug. Of those reporting a previous bed bug feeding, 68% (172/253) reported a pruritic post-bed bug feeding rash and 24% (57/237) reported developing a blister. Overall, 5% (37/705) of ED patients reported currently having a rash, but only 2% (14/698) of ED patients reported currently have bed bugs at home and of those, only 14% (2/14) said they currently had a rash.

Conclusion

While 68% of ED patients reported a pruritic post-bed bug feeding pruritic rash, almost a third of persons did not report developing the rash. Post-bed bug feeding blister reactions are less common. Asking ED patients about a rash had a low sensitivity of 14% (2-43%) and a specificity 95% (93-96%) to identify persons reporting home bed bugs.