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Bed bug infestation

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#### Summary points Bed bugs are bloodfeeding insects that seem to be resurging in developed countries,1 possibly due to international travel and changes in pest control practices.2 Diagnosis of bed bug infestation relies on clinical manifestations of bites and direct observation of the arthropod, which is rarely recognised by those who are bitten.3 Evidence is lacking on the bed bug’s capacity to transmit disease, management of eradication, and the economic impact of infestations. This summary of the available evidence on the diagnosis and management of bed bug infestation aims to help general practitioners identify the clinical signs of bed bug bites and help patients identify and manage infestations. #### Sources and selection criteria We focused on articles published since October 2008 to update Goddard and colleagues’ systematic review.2 We searched PubMed and Embase databases until July 2012, using the search terms “bedbugs [Mesh] OR bed bugs OR bed bug OR Cimex”. We also manually searched textbooks, newspapers, and websites, mainly those listed by the Centers for Disease Control and Prevention (www.cdc.gov/nceh/ehs/topics/bedbugs.htm). Our selection criteria were case reports on more than five patients, and results related to humans in the field of prevention and elimination of bed bugs or clinical manifestations of their bites. The two main species of bed bugs are Cimex lectularius and Cimex hemipterus , which are found in tropical zones and temperate areas, respectively. They are brown, wingless, flat, 2-5 mm …
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Bed bug infestation
Celine Bernardeschi dermatologist 1, Laurence Le Cleach dermatologist 1, Pascal Delaunay
parasitologist-entomologist 2, Olivier Chosidow professor of dermatology 1 3
1AP-HP, Groupe Hospitalier Henri-Mondor, Department of Dermatology, Créteil, France; 2Laboratoire de Parasitologie-Mycologie, Hôpital de l’Archet,
Centre Hospitalier Universitaire de Nice-Université de Nice-Sophia Antipolis/Inserm U1065, Nice, France; 3UPEC-Université Paris Est-Créteil
Val-de-Marne, France
Bed bugs are bloodfeeding insects that seem to be resurging in
developed countries,1possibly due to international travel and
changes in pest control practices.2Diagnosis of bed bug
infestation relies on clinical manifestations of bites and direct
observation of the arthropod, which is rarely recognised by those
who are bitten.3Evidence is lacking on the bed bug’s capacity
to transmit disease, management of eradication, and the
economic impact of infestations. This summary of the available
evidence on the diagnosis and management of bed bug
infestation aims to help general practitioners identify the clinical
signs of bed bug bites and help patients identify and manage
infestations.
What are bed bugs?
The two main species of bed bugs are Cimex lectularius and
Cimex hemipterus, which are found in tropical zones and
temperate areas, respectively. They are brown, wingless, flat,
2-5 mm long insects that resemble apple seeds. If in doubt,
contact an entomologist for precise identification. The bugs
have a multi-stage developmental life cycle and require a human
blood meal every 3-5 days to progress from one stage to another
(fig 1).1After contamination by a few bed bugs, their number
increases exponentially. They can survive for one year without
eating.
Where are bed bugs found?
Over the past 10 years, bed bugs—which had almost disappeared
after the second world war—have increasingly been found in
low budget and upmarket hotels, hostels, bed and breakfasts,
private homes, night trains, cruise ships, and even nursing
homes.1 4
Bed bugs are usually transported passively, mainly in clothing
and luggage, but also on furniture (such as mattresses). Less
commonly, they spread actively from room to room in
communities, mostly through electric wiring or ventilation ducts.
During the day they hide in dark places—such as spaces under
baseboards, loose or peeling wallpaper, and crevices in furniture
and mattresses—and they feed at night. They fear light and
usually avoid smooth or glossy surfaces, such as tiles.2Despite
being easily visible, most people cannot recognise bed bugs—in
a survey conducted in three counties in the United Kingdom,
only 10% of 358 people identified them from pictures (fig 2).3
How common are bed bug infestations?
The idea of a resurgence is based on Australian and European
observational studies that have shown increases in pest manager
interventions (700% increase between 1997-2000 and 2001-04
in Australia,100% rise from 2002 (383 cases) to 2006 (770
cases) in Sweden). There were also increases in calls received
about bed bugs in two London boroughs between 2000 (87 calls)
and 2006 (334 calls), and more inquiries about species (nine
samples of bed bugs submitted to the Department of Medical
Entomology, Institute of Clinical Pathology and Westmead
Hospital, Sydney, Australia in 1997 compared with 37 samples
in 2000). The identification of bed bugs in Australian
laboratories also increased between 2001 and 2004 as did the
number of bed bugs intercepted by Australian customs officials
between 1999 and 2003.5-7
The reasons for this resurgence are unknown. Contributing
factors may include increased domestic and international travel.8
As a consequence, bed bugs, which were most common among
the disadvantaged social classes in the first half of the last
century, can now be encountered in all economic contexts. Other
factors are enhanced resistance to pyrethroid insecticides,2 9
perhaps because of multiple mutations conferring metabolic
resistance,10 and the fact that newer techniques for controlling
cockroaches with bait do not kill bed bugs.11
What are the symptoms of bed bug
infestation?
Because bed bugs feed at night and inject an anaesthetic when
biting, the initial bite is not felt and most patients have no
reaction; moreover, symptom onset, caused by allergic reactions
to saliva, can be delayed.2In 2009, an ethics committee approved
experiment,12 conducted by laboratory scientists who volunteered
Correspondence to: O Chosidow, Service de Dermatologie, Hôpital Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil
Cedex, France olivier.chosidow@hmn.aphp.fr
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BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 1 of 8
ClinicalReview
CLINICAL REVIEW
Summary points
Bed bug infestation seems to be re-emerging worldwide
The diagnosis of bed bug infestation starts with consultation for clinical reactions to bites but symptoms vary greatly
Suspect bed bug bites whenever a patient consults for papules positioned in groups of three or four bites forming a “breakfast-lunch-dinner”
curve or line
Eradication requires patient education and the help of pest eradication professionals to identify pests and perform non-chemical and
chemical interventions
Sources and selection criteria
We focused on articles published since October 2008 to update Goddard and colleagues’ systematic review.2We searched PubMed and
Embase databases until July 2012, using the search terms “bedbugs [Mesh] OR bed bugs OR bed bug OR Cimex”. We also manually
searched textbooks, newspapers, and websites, mainly those listed by the Centers for Disease Control and Prevention (www.cdc.gov/nceh/
ehs/topics/bedbugs.htm). Our selection criteria were case reports on more than five patients, and results related to humans in the field of
prevention and elimination of bed bugs or clinical manifestations of their bites.
to be bitten by bed bugs placed on their arms, confirmed that
reactions to bites manifest up to 11 days later. In a recent
questionnaire based study, only 30% of people living in bed
bug infested households reported skin reactions.13
A 2009 systematic review of 18 articles on clinical reactions to
bed bug bites reported the most common reactions to be 2-5
mm pruritic maculopapular lesions with a central haemorrhagic
punctum, corresponding to the bite site, that are usually located
on uncovered areas of the body.2Skin lesions, such as three or
four bites forming a curve or line (“breakfast-lunch-dinner
alignment,” fig 3A), are suggestive of but not specific to bed
bugs. Other cutaneous symptoms include isolated pruritis,
papules, nodules (fig 3B), and bullous eruptions (fig 3C).14
Some isolated case reports have reported systemic reactions,
such as diffuse urticaria (fig 3D), asthma, and anaphylaxis.2Bed
bug infestation is usually looked for after a clinical diagnosis
of bed bug bites. Similar symptoms in people sharing a bed,
onset of the lesions after travelling or sleeping away from home,
detection of bed bug faecal matter (small dark marks) in or
around the bed, or disappearance of symptoms after changing
sleeping place should trigger suspicion of infestation. However,
the discovery of bed bugs on site confirms active infestation.
What are the differential diagnoses of bed
bug bites?
The most common differential diagnoses are other arthropod
bites,15 especially those of fleas, which form similar three or
four bite lines or curves. Scabies can be confounding but differs
from bed bug bites by the absence of visible puncta and the
predominance of scratching in sites such as forearms, nipples,
and genitals (table 1).
In addition to arthropod bites, there are several dermatological
differential diagnoses.16 These include erythema multiforme,
which is characterised by target lesions on the extremities, and,
sometimes, mucous membrane erosions; Sweet’s syndrome or
acute febrile neutrophilic dermatosis, which includes
papulonodular lesions on the extremities associated with general
symptoms, such as arthralgias, fever, and leucocytosis; bullous
dermatitis, which can affect the mucous cavities and unlike bed
bug bites, can be seen on covered areas of the body; and
vasculitis, which is characterised by polymorphous lesions,
usually on the lower limbs, and sometimes affecting several
organs. When such manifestations are seen, refer the patient to
a dermatologist for further investigations, including a skin
biopsy, if necessary.
What complications can arise from bed
bug infestations?
Scratching can cause secondary infection—usually
Staphylococcus aureus or Streptococcus spp—of skin lesions
(usually impetigo).17
Evidence for disease transmission is less clear. Some pathogens
have been detected in or on bed bugs. These include hepatitis
B virus, Trypanosoma cruzi,1hepatitis C virus,18 HIV,2
Aspergillus spp, and, more recently, meticillin resistant S
aureus,19 but no study has yet demonstrated their vectorial
role—their capacity to transmit diseases to humans.1
The psychological burden of bed bug infestation remains to be
evaluated.
Although the economic impact is not known, bed bugs result
in loss of productivity and costs include those of pest managers’
interventions and replacement of infested furniture.11
How are bed bug infestations managed?
Bed bug control is difficult, mainly because of the parasite’s
hiding behaviour, and also because chemical and non-chemical
technologies need to be combined for optimal effect.1“Integrated
pest management (IPM)” combines detection of the pest with
non-chemical and chemical elimination strategies.
A randomised study conducted in 16 highly infested dwellings,
divided into two groups, compared IPM using traps containing
a killing agent and chemical treatment with diatomaceous earth
dust (D-IPM) versus IPM in which bed bugs were sprayed with
chlorfenapyr (S-IPM) but traps were not used.20 Both groups
received patient targeted information provided by a brochure.
They were also given advice on searching mattresses for hiding
bugs; laundering bed linens weekly; and steaming floors, bed
frames, sofas, and other infested furniture and sites. Insecticides
were applied every two weeks over 10 weeks. Bed bug counts
decreased by 97.6% and 89.7% after the intervention in the
S-IPM and D-IPM groups, respectively.
Such eradication strategies were grouped together in documents
called “Codes of practice” written by experts in Europe, the
United States, and Australia,21 but their use, although
recommended by some municipalities, is not mandatory.
How should bed bug bites be treated?
Guidelines based on expert opinions recommend treating the
symptoms of bed bug bites with topical steroids (such as
hydrocortisone 1%) once or twice a day for no longer than seven
days.22 Prescribe systemic antihistamines only when pruritis is
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BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 2 of 8
CLINICAL REVIEW
associated with sleeping difficulties.22 Antibiotics, either topical
(such as mupirocin or fusidic acid three times a day for 7-10
days) or systemic, might be needed for secondary impetigo,
depending on its severity.23
How can bed bugs be identified and
eradicated?
Patient education
Professionals need to educate patients on how to identify bed
bugs and prevent spread (box). GPs can educate patients to use
a “search and destroy” strategy by providing basic knowledge
about the parasite. They should stress that each insect needs to
bite a human every three to five days to grow and reproduce
but can survive for one year without feeding, and how to detect
and identify the arthropod (fig 4A) or its faecal traces (fig 4B)
in suspected areas, mostly mattresses and cracks and crevices
in wooden furniture. This detection strategy should be applied
whenever travelling.
Non-chemical intervention
Small case series suggest that washing at 60°C, tumble drying
at 40°C, or dry cleaning is effective against all life stages.24 A
recent trial also suggested that freezing can be used to
decontaminate infested clothing.24 However, because bed bugs
can survive for up to one year without feeding, keeping an
infested room vacant is not an effective option.1Disposal of
highly infested items, together with physical removal of bed
bugs and mattress covers and vacuuming, are recommended by
pest managers’ codes of practice,21 even though scientific
evidence of their efficacy is lacking.
The silicates (mostly diatomaceous earth dust) are somewhere
between non-chemical and chemical treatments, and require
further investigation before being used in pest management
programmes.20
Chemical treatment
Although insecticides can be bought in supermarkets and on
the internet, for efficacy and safety reasons they must be used
only by professionals. Clinicians should be aware that misuse
of insecticides may have clinical consequences. The Centers
for Disease Control and Prevention recently identified 111 cases
of illness attributed to insecticide misuse in an attempt to control
bed bugs.25 Pyrethroids were implicated in 89% of those events
and caused neurological, respiratory, and gastrointestinal
symptoms.
The three main groups of currently used insecticides for bed
bug infestations are pyrethroids (the most common),26 insect
growth regulators, and carbamates. The organophosphates, like
dichlorvos, are no longer used in Europe except in impregnated
strips.27 Several large well conducted experimental studies have
found high levels of bed bug resistance to all available
products.9 28 Moreover, product formulation may influence their
efficacy—a laboratory study showed that pyrethroid dusts kill
bed bugs more effectively than sprays.29
Because of different resistance levels among bed bugs, a
combination of insecticides should be applied to all harbourage
areas: mattress seams; cracks in furniture, box springs, and bed
frames; peeling wallpaper; and under carpets and floorboards.21
It is unclear how often these techniques should be applied, but
because insecticides have a limited ovicidal effect, expert
guidelines recommend a second look by the pest manager, with
eventual retreatment 4-20 days after the first intervention. The
length of this waiting time depends on the average temperature
of the infested site.
How can infestation be prevented?
Evidence is lacking about the effectiveness of prevention
procedures. Experts recommend washing mattress encasement
and bed linens at temperatures above 60°C,21 and advise against
purchasing second hand mattresses or furniture. However, it is
not recommended that mattresses are pretreated with insecticides
or preventive insecticide applications.
Early detection of the bed bugs may be an effective way to
prevent their spread. Notably, experimental studies have shown
the efficacy of bed bug traps in attracting the parasites,
especially when combined with carbon dioxide and heat,30 but
their ability to control infestation without the addition of
chemical techniques has not been assessed. Results of a
comparative study indicated that canine detection may be an
option but is operator dependent,31 and further evaluation of this
method is needed.
Acknowledgments: Thanks to Tu-Anh Duong, Arnaud Canet, Sebastien
Larréché, and Pierre Wolkenstein for their collaboration and Janet
Jacobson for editorial assistance.
Contributors: OC conceived the project, which was drafted by CB and
revised by all authors. OC finally approved the article. All authors are
guarantors.
Funding: No special funding received.
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf (available on
request from the corresponding author) and declare: no support from
any organisation for the submitted work; no financial relationships with
any organisations that might have an interest in the submitted work in
the previous three years; no other relationships or activities that could
appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer
reviewed.
1 Delaunay P, Blanc V, Del Giudice P, Levy-Bencheton A, Chosidow O, Marty P, et al.
Bedbugs and infectious diseases. Clin Infect Dis 2011;52:200-10.
2 Goddard J, deShazo R. Bed bugs (Cimex lectularius) and clinical consequences of their
bites. JAMA 2009;301:1358-66.
3 Reinhardt K, Harder A, Holland S, Hooper J, Leake-Lyall C. Who knows the bed bug?
Knowledge of adult bed bug appearance increases with people’s age in three counties
of Great Britain. J Med Entomol 2008;45:956-8.
4 Delaunay P, Blanc V, Dandine M, Del Giudice P, Franc M, Pomares-Estran C, et al.
Bedbugs and healthcare-associated dermatitis, France. Emerging Infect Dis
2009;15:989-90.
5 Doggett S, Greary M, Russell R. The resurgence of bed bugs in Australia. Environ Health
2004;4:30-8.
6 Richards L, Boase CJ, Gezan S, Cameron MM. Are bed bug infestations on the increase
within Greater London. J Environ Health Res 2009;9:17-22.
7 Kilpinen O, Vagn Jensen KM, Kristensen M. Bed bug problems in Denmark, with a
European perspective. In Robinson WH, Bajomi D, eds. Proceedings of the 6th
International Conference on Urban Pests. OOK-Press Kft, 2008:395-9.
8 US Department of Health and Human Services. Joint statement on bed bug control in the
United States from the US Centers for Disease Control and Prevention (CDC) and the
US Environmental Protection Agency (EPA). 2010. www.cdc.gov/nceh/ehs/publications/
bed_bugs_cdc-epa_statement.htm.
9 Tawatsin A, Thavara U, Chompoosri J, Phusup Y, Jonjang N, Khumsawads C, et al.
Insecticide resistance in bedbugs in Thailand and laboratory evaluation of insecticides
for the control of Cimex hemipterus and Cimex lectularius (Hemiptera: Cimicidae). J Med
Entomol 2011;48:1023-30.
10 Zhu F, Wigginton J, Romero A, Moore A, Ferguson K, Palli R, et al. Widespread distribution
of knockdown resistance mutations in the bed bug, Cimex lectularius (Hemiptera:
Cimicidae), populations in the United States. Arch Insect Biochem Physiol 2010;73:245-57.
11 Doggett SL, Dwyer DE, Peñas PF, Russell RC. Bed bugs: clinical relevance and control
options. Clin Microbiol Rev 2012;25:164-92.
12 Reinhardt K, Kempke D, Naylor RA, Siva-Jothy MT. Sensitivity to bites by the bedbug,
Cimex lectularius. Med Vet Entomol 2009;23:163-6.
13 Potter Mf, Haynes KF, Connelly K. The sensitivity spectrum: human reactions to bed bug
bites. Pest Control Technol 2010;38:70-4.
14 DeShazo RD, Feldlaufer MF, Mihm MC Jr, Goddard J. Bullous reactions to bedbug bites
reflect cutaneous vasculitis. Am J Med 2012;125:688-94.
15 Steen CJ, Carbonaro PA, Schwartz RA. Arthropods in dermatology. J Am Acad Dermatol
2004;50:819-42.
16 Rook A, Burns T. Rook’s textbook of dermatology. Wiley-Blackwell, 2010.
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BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 3 of 8
CLINICAL REVIEW
Patient education
Detection
Look for brown insects no bigger than apple seeds on the mattress, sofa, and curtains and in darker places in the room (especially
cracks in the walls, crevices in box springs, and furniture)
Look for black spots on the mattress or blood traces on the sheets
Elimination
Contact a pest management company
Wash clothes at 60°C or freeze delicate clothing, vacuum, and clean your home before the pest manager visits
Collaborate with professionals who are used to dealing with bed bug infestation to increase eradication efficacy
Prevention
Carefully examine secondhand furniture to assure the absence of bed bugs before purchase so as not to contaminate your home
When sleeping in a hotel, even an upmarket establishment, lift mattresses to look for bed bugs or black spots
Do not leave luggage in dark places, near furniture, or close to your bed. Before going to bed, close suitcases and put them in the
bathroom—in the bathtub or shower stall
Tips for non-specialists
Inform patients who are about to travel of the resurgence of bed bugs and teach them how to recognise the arthropod
Suspect bed bug infestations in patients who consult for pruritic linear papules, especially when similar symptoms are found in people
sharing a bed, and onset of the lesions after travelling or sleeping away from home Look for atypical skin reactions (blisters, crusts,
necrosis) or general symptoms (fever) that may justify skin biopsy or further dermatological investigations
Encourage infested patients to call a pest manager as soon as the pest has been identified
Prescribe a mild potency topical steroid treatment once or twice a day for seven days to treat symptomatic bed bug bites
Additional educational resources
Resources for healthcare professionals
University of Kentucky (www.ca.uky.edu/entomology/entfacts/entfactpdf/ef636.pdf)—Comprehensive lesson on bed bugs
Centers for Disease Control and Prevention (www.cdc.gov/nceh/ehs/topics/bedbugs.htm)—Link to various articles on bed bugs
NHS Choices (http://nhs.uk/conditions/bites-insect/pages/introduction.aspx)—Clinical knowledge summary about insect bites
Resources for patients
Easing bedbug anxiety: what you need to know about the recent bedbug resurgence. Harvard’s Women’s Health Watch 2011;18:7
Up to Date (www.uptodate.com/contents/bedbugs?source=search_result&search=bedbugs&selectedTitle=1~10)—Provides accurate
general knowledge about bed bugs
Bed-Bugs.co.uk (http://bed-bugs.co.uk/)—Provides an interesting picture gallery of bed bugs and their bites, together with practical tips
for eradication
Pest Control UK (www.pestcontrol-uk.org/pests/bed-bugs)—DIY control of bed bugs
Questions for future research
What are the risk factors for bed bug infestation?
What are the psychological complications of bed bug bites?
Can bed bugs transmit diseases to humans?
What is the best eradication strategy?
What are the mechanisms of pesticide resistance?
Are prevention approaches (sniffing dogs, resin strips, traps) effective?
17 Heukelbach J, Hengge UR. Bed bugs, leeches and hookworm larvae in the skin. Clin
Dermatol 2009;27:285-90.
18 Silverman AL, Qu LH, Blow J, Zitron IM, Gordon SC, Walker ED. Assessment of hepatitis
B virus DNA and hepatitis C virus RNA in the common bedbug (Cimex lectularius L.) and
kissing bug (Rodnius prolixus). Am J Gastroenterol 2001;96:2194-8.
19 Lowe CF, Romney MG. Bedbugs as vectors for drug-resistant bacteria. Emerging Infect
Dis 2011;17:1132-4.
20 Wang C, Gibb T, Bennett GW. Evaluation of two least toxic integrated pest management
programs for managing bed bugs (Heteroptera: Cimicidae) with discussion of a bed bug
intercepting device. J Med Entomol 2009;46:566-71.
21 Doggett SL; Australian Environmental Pest Managers Association. A code of practice for
the control of bed bug infestations in Australia. Westmead Hospital, 2011. www.medent.
usyd.edu.au/bedbug/bedbug_cop.htm.
22 Management of simple insect bites: where’s the evidence? Drug Ther Bull 2012;50:45-8.
23 Koning S, van der Sande R, Verhagen AP, van Suijlekom-Smit LWA, Morris AD, Butler
CC, et al. Interventions for impetigo. Cochrane Database Syst Rev 2012;1:CD003261.
24 Naylor RA, Boase CJ. Practical solutions for treating laundry infested with Cimex lectularius
(Hemiptera: Cimicidae). J Econ Entomol 2010;103:136-9.
25 Centers for Disease Control and Prevention (CDC). Acute illnesses associated with
insecticides used to control bed bugs-seven states, 2003-2010. Morb Mortal Wkly Rep
2011;60:1269-74.
26 Davies TGE, Field LM, Williamson MS. The re-emergence of the bed bug as a nuisance
pest: implications of resistance to the pyrethroid insecticides. Med Vet Entomol
2012;26:241-54.
27 Lehnert MP, Pereira RM, Koehler PG, Walker W, Lehnert MS. Control of Cimex lectularius
using heat combined with dichlorvos resin strips. Med Vet Entomol 2011;25:460-4.
28 Kilpinen O, Kristensen M, Jensen K-MV. Resistance differences between chlorpyrifos
and synthetic pyrethroids in Cimex lectularius population from Denmark. Parasitol Res
2011;109:1461-4.
29 Romero A, Potter MF, Haynes KF. Bed bugs; are dusts the bed bug bullet? Pest Manag
Prof 2009;77:22-30.
30 Wang C, Gibb T, Bennett GW, McKnight S. Bed bug (Heteroptera: Cimicidae) attraction
to pitfall traps baited with carbon dioxide, heat, and chemical lure. J Econ Entomol
2009;102:1580-5.
31 Wang C, Cooper R. Detection tools and techniques. Pest Control Technol 2011;39:72,
74, 76, 78-9.
32 Chosidow O. Scabies and pediculosis. Lancet 2000;355:819-26.
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BMJ 2013;346:f138 doi: 10.1136/bmj.f138 (Published 22 January 2013) Page 4 of 8
CLINICAL REVIEW
33 Del Giudice P, Blanc-Amrane V, Bahadoran P, Caumes E, Marty P, Lazar M, et al.
Pyemotes ventricosus dermatitis, southeastern France. Emerg Infect Dis 2008;14:1759-61.
Accepted: 03 January 2013
Cite this as: BMJ 2013;346:f138
© BMJ Publishing Group Ltd 2013
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CLINICAL REVIEW
Table
Table 1| Bed bug bites versus other arthropod bites: main clinical and epidemiological features*
ContextTiming of pruritusLocationClinical features on examinationArthropod
TravellingMorningUncovered areas3-4 bites in a line or curveBed bugs
Pet owners or rural livingDaytimeLegs and buttocks3-4 bites in a line or curveFleas
Worldwide distributionAnopheles spp night; Culex
spp night; Aedes spp day
Potentially anywhereNon-specific urticarial papulesMosquitoes
Children, parents, or contact with
children
AnyScalp, ears, and neckLive lice on the head associated with
itchy, scratched lesions
Head lice32
Homeless people, developing
countries
AnyBackExcoriated papules and
hyperpigmentation; live lice inside clothes
Body lice32
Sexually transmitted, households or
institutions
NightInterdigital spaces, forearms,
breasts, genitalia
Vesicles, burrows, nodules and
non-specific secondary lesions
Sarcoptes scabiei mites
(scabies)32
Pet owners or hikersAsymptomaticPotentially anywhereErythema migrans or ulcerTicks
People exposed to woodworm
contaminated furniture (P
ventricosus is a woodworm parasite)
Any time when inside habitatUnder clothesComet sign,33 a linear erythematous
macular tract
Pyemotes ventricosus
Rural livingImmediate pain, no itchingFace and armsNecrosis (uncommon)Spiders
*It is difficult to diagnose a bite. Diagnosis relies on an array of arguments, none of which is specific by itself; it is the association of elements that is suggestive.
Any arthropod bite can be totally asymptomatic.
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Figures
Fig 1 The life cycle of the bed bug (adapted from Delaunay and colleagues1)
Fig 2 Bed bug nymph (1-4 mm) and adult (5-7 mm): Cimex lectularius
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Fig 3 Clinical manifestations of bed bug bites: three or four skin lesions are often seen in a “breakfast (1), lunch (2), dinner
(3)” distribution (A) or “wheel” distribution (B). Atypical bullous lesions (C) and urticaria (D)
Fig 4 To educate patients to the “search and destroy” strategy, GPs should show them pictures of (A) bed bugs and their
typical hideouts and (B) bed bug faecal traces on the mattress
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... Tabel 1: Kenmerken van de verschillende bijt-en steekwonden veroorzaakt door insecten en geleedpotigen (2,6,9). ...
Article
The bed bug: a bad bug? The common bed bug, Cimex lectularius, is a bloodsucking ectoparasite which attacks mammals and is on the rise since the beginning of the early 21st century. They are brown and flat. Skin lesions appear after the painless bite, often during the predawn hours. Small, purpuric macules develop into erythematous, indurated papules on exposed areas of skin of the face, neck and extremities, and resolve over the course of 2 weeks. Often, a linear or cluster configuration of 3 to 4 lesions (‘breakfast, lunch and dinner’) appears. Pruritic wheal reactions represent a type 1 hypersensitivity reaction elicited by the parasite’s saliva antigens. The clinical differential diagnosis is broad and may include other insect and arthropod bites and stings, scabies infestation, dermatitis herpetiformis, ecthyma, etc. There is no evidence that bed bugs are vectors and transmit human pathogens. They are responsible for considerable physical irritation and significant psychological distress. Very rarely, the patient could develop anemia or anaphylaxis. Control involves treating both the patient’s symptoms and the cause by the eradication of the infestation, a challenge that may require a professional exterminator for an integrated pest management strategy. “Good night, sleep tight, don’t let the bed bugs bite!”
Article
Background With the increase of international travel and development of insecticide resistance, a reemergence of the bed bug has been observed since the 2000’s and becoming a worldwide public health problem. Hospital and other medical settings haven’t been spared while the cases reported remains limited. However, there is no specific recommendation for the healthcare settings emanating from learned society. Aims We report our experience with a bed bug infestation of a medical unit, in the French University Hospital Center of Brest, caused by the admission of a patient carrier in October 2020. We described the practical methods we used to control bed bugs infestation, we evaluated the cost of this episode and we created a specific procedure to take care of the patients at risk or known carrier of bed bugs. Findings The decision to close the unit for a global treatment was taken after the investigations using a sniffing dog revealed that 4 rooms were infested. The closure lasted 24 days. We estimated the total cost of the infestation to approximately 400 000 US dollars. No other wave of infestation occurred. We created a specific protocol of care for patient known carrier or at risk of carriage of bed bug to graduate strategy of control. Conclusion Bed bugs infestation in Health facilities has a major impact on the care of patients and relevant economic consequences. Prevention and education policies are an essential starting point to response to the scale of the phenomenon.
Article
Bed bugs are known to carry several microorganisms. The purpose of this study was to assess the prevalence of bed bug infestation in two rural areas of Senegal and determine the species present in the population. A screening was conducted to detect some arthropod associated pathogenic bacteria in bed bugs and to evaluate the prevalence of endosymbiont carriage. One survey took place in 17 villages in Niakhar and two surveys in Dielmo and Ndiop and surroundings area in the same 20 villages. Bed bugs collected were identified morphologically and by MALDI-TOF MS tools. Microorganisms screening was performed by qPCR and confirmed by sequencing. During the survey in the Niakhar region, only one household 1/255 (0.4%) in the village of Ngayokhem was found infested by bed bugs. In a monitoring survey of the surroundings of Dielmo and Ndiop area, high prevalence was found during the two rounds of surveys in 65/314 (21%) in 16/20 villages (January–March) and 93/351 (26%) in 19/20 villages (December). All bed bugs were morphologically identified as the species Cimex hemipterus, of which 285/1,637 (17%) were randomly selected for MALDI-TOF MS analysis and bacteria screening. Among the Bacteria tested only Wolbachia (Alphaproteobacteria, Rickettsiales, Rickettsiaceae) DNA was found in 248/276 (90%) of the bedbugs. We briefly describe a high level of non-generalized bed bug infestation in rural Senegal and the diversity of Wolbachia strains carried by C. hemipterus. This study opens perspectives for raising household awareness of bed bug infestations and possibilities for appropriate control.
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We report patients in their homes in France who had cutaneous lesions caused by Anthrenus sp. larvae during the end of winter and into spring. These lesions mimic bites but are allergic reactions to larvae hairs pegged in the skin. These lesions should be distinguished from bites of bed bugs or fleas.
Article
Purpose of the review: This review will update pediatric providers on the recent data regarding the epidemiology, diagnosis, and treatment of common skin infestations affecting children and adolescents. Recent findings: Standard superficial skin biopsy for scabies and the vacuum method for head lice can increase diagnostic accuracy and efficiency. There is growing resistance to some of the traditional treatments for scabies and head lice, and progress has been made in finding newer and potentially more effective treatments, such as oral moxidectin for scabies and abametapir for head lice. Recent studies have established the safety of traditional treatments, such as permethrin and oral ivermectin in infants and small children. Summary: Permethrin and ivermectin are both considered safe and effective for children and adolescents with scabies. Permethrin is generally considered safe in infants less than two months of age. Proper application of permethrin is critical, and providers should emphasize proper application technique. Treatment of head lice should only be initiated with active infestations. Resistance to permethrin continues to increase and other options are now available, including an over-the-counter topical ivermectin formulation. Identification and eradication of bed bug infestations are crucial in preventing bedbug bites.
Article
Indoor pests, and the allergens they produce, adversely affect human health. Surprisingly, however, their effects on indoor microbial communities have not been assessed. Bed bug (Cimex lectularius) infestations pose severe challenges in elderly and low-income housing. They void large amounts of liquid feces into the home environment, which might alter the indoor microbial community composition. In this study, using bed bug-infested and uninfested homes, we showed a strong impact of bed bug infestations on the indoor microbial diversity. Floor dust samples were collected from uninfested and bed bug-infested homes and their microbiomes were analyzed before and after heat interventions that eliminated bed bugs. The microbial communities of bed bug-infested homes were radically different from those of uninfested homes, and the bed bug endosymbiont Wolbachia was the major driver of this difference. After bed bugs were eliminated, the microbial community gradually shifted toward the community composition of uninfested homes, strongly implicating bed bugs in shaping the dust-associated environmental microbiome. Further studies are needed to understand the viability of these microbial communities and the potential risks that bed bug-associated microbes and their metabolites pose to human health.
Conference Paper
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Abstract Based on historical data on the number of inquiries to the advisory service at the Danish Pest Infestation Laboratory we have tried to analyse the variation in bed bug infestations in Denmark since the 1950s. The bed bug problems in Denmark have gone from low levels in the 1950s, gradually increasing to a peak in the mid-1980s. From there on the problems diminished, but were still present. In the last 10 years the problems are increasing again. The available information from other European countries seems to indicate that this ...
Article
Full-text available
Based on historical data on the number of inquiries to the advisory service at the Danish Pest Infestation Laboratory we have tried to analyse the variation in bed bug infestations in Denmark since the 1950s. The bed bug problems in Denmark have gone from low levels in the 1950s, gradually increasing to a peak in the mid-1980s. From there on the problems diminished, but were still present. In the last 10 years the problems are increasing again. The available information from other European countries seems to indicate that this is the same situation in many countries. One possible reason for the recent increase in the bed bug problems is resistance against the available insecticides. To investigate this possibility we collected bed bugs from 20 different locations in Denmark and tested their sensitivity against chlorpyrifos, permethrin and deltamethrin; the most important insecticides registered in Denmark for bed bug control. Compared with a sensitive US strain there was widespread resistance against permethrin and deltamethrin whereas only cases of reduced sensitivity to chlorpyrifos were found. The resistance to pyrethroids is comparable with recent results from the US and UK, indicating that it might be found also in many other countries. This means that the pyrethroids are not a good solution for controlling bed bugs whereas chlorpyrifos continues to be active. However, chlorpyrifos will probably not be available for Danish pest control operators anymore, leaving no effective insecticides for the treatment of bed bug infestations. Therefore, there is an urgent need for the development and registration of new control methods.
Article
The common bed bug, Cimex lectularius, is a wingless, reddish-brown insect that requires blood meals from humans, other mammals, or birds to survive. Bed bugs are not considered to be disease vectors, but they can reduce quality of life by causing anxiety, discomfort, and sleeplessness. Bed bug populations and infestations are increasing in the United States and internationally. Bed bug infestations often are treated with insecticides, but insecticide resistance is a problem, and excessive use of insecticides or use of insecticides contrary to label directions can raise the potential for human toxicity. To assess the frequency of illness from insecticides used to control bed bugs, relevant cases from 2003-2010 were sought from the Sentinel Event Notification System for Occupational Risks (SENSOR)-Pesticides program and the New York City Department of Health and Mental Hygiene (NYC DOHMH). Cases were identified in seven states: California, Florida, Michigan, North Carolina, New York, Texas, and Washington. A total of 111 illnesses associated with bed bug-related insecticide use were identified; although 90 (81%) were low severity, one fatality occurred. Pyrethroids, pyrethrins, or both were implicated in 99 (89%) of the cases, including the fatality. The most common factors contributing to illness were excessive insecticide application, failure to wash or change pesticide-treated bedding, and inadequate notification of pesticide application. Although few cases of illnesses associated with insecticides used to control bed bugs have been reported, recommendations to prevent this problem from escalating include educating the public about effective bed bug management.
Article
OBJECTIVE:Historical clinical studies suggest the potential for insect-borne transmission of human hepatitis viruses. Studies of hepatitis B virus (HBV) persistence in insects were performed before the advent of molecular techniques, and studies to assess possible insect-borne transmission of hepatitis viruses have not yet been performed. The aim of this study was to determine, using molecular techniques, whether HBV and hepatitis C virus (HCV) persist in and are excreted in the feces of the bedbug Cimex lectularius L. and kissing bug Rodnius prolixus after an infectious meal.METHODS:Blood-feeding insects from the insect order Hemiptera (Cimex lectularius L. and Rhodnius prolixus) were fed on blood from infected patients with high titers of HBV, HCV, and control uninfected patients. Insects and insect excrement were collected at weekly intervals and tested for HBV DNA and HCV RNA using the polymerase chain reaction.RESULTS:HBV DNA was detected in bedbugs and excrement up to 6 wk after feeding on an infectious meal. HBV DNA was also detected in most kissing bugs and excrement up to 2 wk after feeding. HCV RNA was not detected in bedbugs at any time after feeding.CONCLUSIONS:We did not detect HCV RNA in bedbugs after feeding on an infectious meal. Our data provide molecular evidence to suggest that HBV may persist in Hemiptera. Additional studies are ongoing to determine whether this viral persistence is capable of infection.
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Granuloma annulare Necrobiosis lipoidica Granuloma multiforme References
Article
There has been a worldwide resurgence of bedbug infestations. Bites by these insects may cause mild or severe cutaneous reactions, and anaphylaxis has been reported. Little is known about the most severe cutaneous reactions, termed bullous or complex reactions. To study the time course and histopathologic findings of complex (bullous) cutaneous reactions to bedbugs in order to determine the optional treatment for them. We prospectively photographed bullous reactions to observed bedbug bites at 30 minutes; 6, 12, 24, 36, 48, and 72 hours; 1, 2, 3, and 4 weeks, and biopsied reactions at 30 minutes, and 6, 12, and 24 hours. We also reviewed Internet postings and the available medical literature on bullous reactions after bedbug bites. MAIN OUTCOMES AND MEASURES: Correlations between clinical and histologic findings using both routine and immunofluorescent techniques. Bullous reactions to bedbugs are not rare. Of 357 photographs of bedbug bites posted on the Internet, 6% were bullous. In an individual with previous bullous reactions, experimental bedbug bites were associated with a progression of cutaneous responses at bite sites from immediate, pruritic, edematous lesions to a late-in-time macule, which evolved into bullous reactions by 24 hours. Bullous lesions eventually lysed but took weeks to heal. Histopathologic evaluation of bullous reactions showed a polymorphous picture with histologic evidence of an urticarial-like reaction early on that rapidly developed into a hybrid leukocytoclastic vasculitis. This vasculitis was initially neutrophilic but developed into a destructive, necrotizing, eosinophil-rich vasculitis with prominent infiltration of CD 68+ histiocytes and collagen necrobiosis. This histologic picture is similar to the dermal vasculitis in patients with Churg-Strauss vasculitis. Historically, bedbug bite reactions have been considered to be of minor medical significance. However, the findings presented here demonstrate that the not-uncommon bullous reactions to bedbug bites reflect the presence of a local, highly destructive, cutaneous vasculitis. The histologic features of these reactions resemble those occurring in the Churg-Strauss syndrome. Therefore, efforts to prevent further bites and monitor for evidence of systemic vasculitis should be made in patients with bullous reactions to bedbug bites. Topical treatment with high potency corticosteroids may be useful in the treatment of bullous reactions.
Article
Impetigo is a common, superficial bacterial skin infection, which is most frequently encountered in children. There is no generally agreed standard therapy, and guidelines for treatment differ widely. Treatment options include many different oral and topical antibiotics as well as disinfectants. This is an updated version of the original review published in 2003. To assess the effects of treatments for impetigo, including non-pharmacological interventions and 'waiting for natural resolution'. We updated our searches of the following databases to July 2010: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched online trials registries for ongoing trials, and we handsearched the reference lists of new studies found in the updated search. Randomised controlled trials of treatments for non-bullous, bullous, primary, and secondary impetigo. Two independent authors undertook all steps in data collection. We performed quality assessments and data collection in two separate stages. We included 57 trials in the first version of this review. For this update 1 of those trials was excluded and 12 new trials were added. The total number of included trials was, thus, 68, with 5578 participants, reporting on 50 different treatments, including placebo. Most trials were in primary impetigo or did not specify this.For many of the items that were assessed for risk of bias, most studies did not provide enough information. Fifteen studies reported blinding of participants and outcome assessors.Topical antibiotic treatment showed better cure rates than placebo (pooled risk ratio (RR) 2. 24, 95% confidence interval (CI) 1.61 to 3.13) in 6 studies with 575 participants. In 4 studies with 440 participants, there was no clear evidence that either of the most commonly studied topical antibiotics (mupirocin and fusidic acid) was more effective than the other (RR 1.03, 95% CI 0.95 to 1.11).In 10 studies with 581 participants, topical mupirocin was shown to be slightly superior to oral erythromycin (pooled RR 1.07, 95% CI 1.01 to 1.13). There were no significant differences in cure rates from treatment with topical versus other oral antibiotics. There were, however, differences in the outcome from treatment with different oral antibiotics: penicillin was inferior to erythromycin, in 2 studies with 79 participants (pooled RR 1.29, 95% CI 1.07 to 1.56), and cloxacillin, in 2 studies with 166 participants (pooled RR 1.59, 95% CI 1.21 to 2.08).There was a lack of evidence for the benefit of using disinfectant solutions. When 2 studies with 292 participants were pooled, topical antibiotics were significantly better than disinfecting treatments (RR 1.15, 95% CI 1.01 to 1.32).The reported number of side-effects was low, and most of these were mild. Side-effects were more common for oral antibiotic treatment compared to topical treatment. Gastrointestinal effects accounted for most of the difference.Worldwide, bacteria causing impetigo show growing resistance rates for commonly used antibiotics. For a newly developed topical treatment, retapamulin, no resistance has yet been reported. There is good evidence that topical mupirocin and topical fusidic acid are equally, or more, effective than oral treatment. Due to the lack of studies in people with extensive impetigo, it is unclear if oral antibiotics are superior to topical antibiotics in this group. Fusidic acid and mupirocin are of similar efficacy. Penicillin was not as effective as most other antibiotics. There is a lack of evidence to support disinfection measures to manage impetigo.
Article
A global resurgence of bed bugs (Hemiptera: Cimicidae) has led to renewed scientific interest in these insects. The current bed bug upsurge appears to have started almost synchronously in the late 1990 s in Europe, the U.S.A. and Australia. Several factors have led to this situation, with resistance to applied insecticides making a significant contribution. With a growing number of insecticides (DDT, carbamates, organophosphates etc.) being no longer available as a result of regulatory restrictions, the mainstay chemistry used for bed bug control over the past few decades has been the pyrethroid insecticides. With reports of increasing tolerance to pyrethroids leading to control failures on the rise, containing and eradicating bed bugs is proving to be a difficult task. Consequently, several recent studies have focused on determining the mode of action of pyrethroid resistance in bed bug populations sourced from different locations. Correct identification of the factor(s) responsible for the increasing resistance is critical to the development of effective management strategies, which need to be based, wherever possible, on firm scientific evidence. Here we review the literature on this topic, highlighting the mechanisms thought to be involved and the problems currently faced by pest control professionals in dealing with a developing pandemic.