Managing bed bug infestations

Bed bugs spread by hitching a ride on an unsuspecting host – don’t be that host

Bed bugs have been part of human existence since antiquity. In the United States, bed bug infestations were quite common up until the mid-1900s. At that time, widespread use of DDT, one of the first, now-banned chemicals used as a pesticide, almost completely eradicated the bug. It would take almost half a century for the bed bug to recover.


The common bed bug (Cimex lectularius) is a small wingless insect that, when unfed, is slightly larger than an apple seed. In the earliest stage of the bed bug’s life, the insect is about 1 mm in length and appears cream colored. As the bug matures, it gets darker and larger, finally assuming a flattened oval shape. Bed bugs are often mistaken for ticks or small cockroaches.

Biologically, bed bugs belong to the same insect order as aphids and cicadas. The mouth of a bed bug is specially modified to permit feeding on humans and other warm-blooded animals. The insect grabs and pierces an individual’s skin, injects an anticoagulant and other chemicals that liquefy epidermal tissue, and then sucks out the liquid.

It only takes about 10 to 20 minutes for an adult bed bug to completely engorge with blood while feeding on a human, after which the bed bug detaches (Usinger, 1966). Once satiated, the bed bug will not feed for about a week, although it is possible for the bug to survive for months without feeding.

Physical findings

Most often bed bugs bite the exposed surfaces of a patient’s face, neck, and arms; however bites may occur anywhere on the body (Honig, 1986). The bites are usually painless and the victim is not even aware of being bitten until the next morning. However, some individuals report being awaked by the bite, which obviously interrupts an individual’s sleep cycle.

Bites often appear as irregularly spaced petechiae and are caused by capillary hemorrhage. In many cases, the bite produces small red raised bumps that do not appear to contain fluid (erythematous papules) although some may. In other cases, there is no bump, but the bite leaves a small (1 cm) red dot (macule) that characteristically turns into a wheal within a few days. Scratching may facilitate opportunistic infections (Thomas, Kihiczak, & Schwartz, 2004).

Reactions to the bite may be delayed for nine days or more (Sansom, Reynolds, & Peachey, 1992). With multiple bites, the patient may exhibit a reddish rash or urticaria (Scarupa & Economides, 2006). There is a single case of anaphylaxis resulting in death from bed bug bites in the published medical literature (Parsons, 1955). Doctors in that case originally misdiagnosed the condition as a heart attack.

Beside the cutaneous evidence, there are other infestation signs that EMS personnel may observe when entering into patient homes. The bugs are active primarily at night. During the day, bed bugs hide in tiny cracks and crevices near where patients sleep. Although the bugs are not social creatures in the same way that ants and bees are, bed bugs often share the same hiding places. Since so many bugs come and go from the same hiding place, rescuers can often see tiny dark spots and stains composed of excrement near the hideout entrance. In addition, EMS personnel may see similar dark spots on bedding, especially near the seams.


In most cases, bed bug bites do not require complicated medical treatment. Keeping the affected area clean can help to prevent secondary opportunistic infection that can occur with repeated scratching. If the affected area is large, topical antihistamines may help to reduce itching.

EMS precautions

EMS and first responders may enter homes where infestation is present. Since bed bugs cannot fly or jump, the most common mechanism by which bed bugs transfer from one place to another is by hitching a ride on the clothing or in the luggage of an unsuspecting host (Davies, Field, & Williamson, 2012). If infestation is suspected or confirmed, wear protective shoe coverings and place them in a plastic bag before getting into the ambulance.

If possible, avoid placing personal items such as coats on the bed, sofa, or near sleeping areas. Place medical bags on table tops or leave them outside of the residence. If you must have them at the patient’s bedside, place a plastic bag on the floor first. Then place your bag on the plastic.

As a matter of policy, your agency should consider replacing soft EMS bags with hard cases.

Using the patient’s bedding or sheets to facilitate a transfer greatly increase the chances of transferring bed bugs to your ambulance and to the hospital. If you must use the patient’s own sheet, verify that it is not infested before transferring the patient to the stretcher. If the patient’s clothing is infested, it is probably worth the effort to help the patient into a change of clothing.

Minimizing exposure

Bed bugs are very difficult to get rid of once an infestation occurs. One cannot simply apply a topical insect repellant and be safe. Conventional bug or mosquito repellant has no effect on bed bugs (Potter, 2012). Most commercially available insect foggers are ineffective against bed bug infestations (Jones & Bryant, 2012). Effective eradication almost always involves a professional who knows where to look for the hiding bugs.

EMS agencies must take a proactive approach to preventing the transfer of bed bugs to the ambulance, hospital, or back to the crew quarters. The National Pest Management Association recommends, as a first step, the development of an action plan or policy on how to respond to an infested environment. In addition, they recommend that all medical personnel attend a bed bug awareness and education program.


Davies, T. G., Field, L. M., & Williamson, M. S. (2012). The re-emergence of the bed bug as a nuisance pest: Implications of resistance to the pyrethroid insecticides. Medical and Veterinary Entomology, 26(3), 241-254. doi:10.1111/j.1365-2915.2011.01006.x

Doggett, S. L., & Russell, R. C. (2009). Bed bugs—What the GP needs to know. Australian Family Physician, 38(11), 880–884.

Honig, P. J. (1986). Arthropod bites, stings, and infestations: their prevention and treatment. Pediatric Dermatology, 3(3), 189–197. doi:10.1111/j.1525-1470.1986.tb00512.x

Jones, S. C., & Bryant, J. L. (2012). Ineffectiveness of over-the-counter total-release foggers against the bed bug (Heteroptera: Cimicidae). Journal of Economic Entomology, 105(3), 957-963. doi:10.1603/EC12037

National Pest Management Association. (n. d.). Response to bed bugs in medical facilities. Retrieved from

Parsons, D. J. (1955). Bed bug bite anaphylaxis misinterpreted as coronary occlusion. Ohio Medicine: Journal of the Ohio Medical Association, 51(7), 669.

Potter, M. F. (2012). Bed bugs. Retrieved from

Szalanski, A. L., Austin, J. W., McKern, J. A., Steelman, C. D., & Gold, R. E. (2008). Mitochondrial and ribosomal internal transcribed spacer (ITS1) diversity of the bed bug Cimex lectularius L. (Heteroptera: Cimicidae). Journal of Medical Entomology, 45(2), 229–236. doi:10.1603/0022-2585(2008)45[229:MARITS]2.0.CO;2

Sansom, J. E., Reynolds, N. J., & Peachey, R. D. G. (1992). Delayed reaction to bed bug bites. Archives of Dermatology, 128(2), 272–273. doi:10.1001/archderm.1992.01680120148025

Scarupa, M. D, & Economides, A. E. (2006). Letter to the editor: Bedbug bites masquerading as urticaria. Journal of Allergy and Clinical Immunology, 117(6), 1508–1509. doi:10.1016/j.jaci.2006.03.034

Thomas, I., Kihiczak, G. G., & Schwartz, R. A. (2004). Bedbug bites: A review. International Journal of Dermatology, 43(6), 430–433. doi:10.1111/j.1365-4632.2004.02115.x

Usinger, R. (1966). Monograph of Cimicidae, Thomas Say Foundation, Vol. 7. Entomological Society of America, College Park, MD.

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