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All things bed bugs: a primer for Nephrology Nurses.

Cimex lectularius, commonly known as bed bugs, have plagued the world for centuries. Once thought to be a problem limited to developing countries or poor hygiene, bed bugs can be found in virtually any area where people sleep. It is well documented that bedbugs are a public health concern and a burden on society in both social and economic terms worldwide (Environmental Protection Agency [EPA], 2016a; Lai, Ho, Glick, & Jadeo, 2016).

Bed bugs are also a potential problem in nephrology patient settings. Members of the American Nephrology Nurses Association (ANNA) across the country have been writing and asking about bed bug treatment and protocols in the ANNA Open Forum since 2011. A search of ANNA Connected with the search term 'bed bugs' revealed 32 results.

Infestations on the Rise

Bed bugs may be found anywhere there is a sleeping human body and can travel up to 100 feet on their own to find a host. There was a dramatic drop in bed bug infestation in the 1950s due to the development of dichlorodiphenyltrichloroethane (DDT), but the country has seen a resurgence since the 1990s (Thomas, Wrobel, & Brown, 2013). The 2011 Bugs Without Borders Survey conducted by the National Pest Management Association (2017) revealed that 99% of pest management professionals encountered bed bug infestations, compared to 11% more than 10 years ago. The Orkin pest control company publishes an annual list of the top 50 bed bug cities based on bedbug treatments and inspections (Orkin, 2017). The 2016 list is based on residential and commercial treatment data from the metro areas where Orkin performed the most bed bug treatments from December 1, 2015, to November 30, 2016. The top 10 cities in rank order were (the number in parentheses is the change in rank since 2015):

1. Baltimore (+9)

2. Washington, D.C. (+1)

3. Chicago (-2)

4. New York

5. Columbus, Ohio

6. Los Angeles (-4)

7. Detroit

8. Cincinnati

9. Philadelphia (-3)

10. San Francisco-Oakland-San Jose (+4)

Typically, bed bugs live in a 5- to 20-foot area from the host, but can be found up to 100 feet away. Bed bugs like to hide in clothing and crevices, and are easily transported from one location to another in clothing, travel bags, and backpacks, promoting their spread to new locations. Bed bugs are sometimes transferred from one location to another in non-clothing/luggage articles, such as boxes, computers, and toys. Adult bed bugs can live for over one year and lay over 500 eggs in their lifetime. There are five stages in the bed bug lifecycle, and blood is needed at each stage (see Figure 1). In addition to a blood source, bed bugs must shed their outer skin (molt) to progress to the next stage. It is this dead skin that often indicates a bed bug infestation.

Bed Bug Bites

Bed bugs locate their victim through detection of heat, body odor, and carbon dioxide (Center for Invasive Species Research, University of California, Riverside, 2016) and typically bite when people are in their deepest sleep, either late at night or early in the morning (Michigan Department of Community Health, 2010). The saliva of the bed bug contains an anesthetic and an anticoagulant, so the individual is not aware of the bite (Williams & Willis, 2012). Bed bugs typically feed every three to seven days, but can survive for up to a year without eating (National Pesticide Information Center, n.d.; Thomas et al., 2013). While some individuals may develop an allergic reaction to the bite, the typical presentation may be delayed for days or weeks, and ranges from small reddened areas to itchy raised welts (Thomas et al, 2013). Secondary infections may develop as a result of bed bug bites, requiring treatment with antihistamines, corticosteroids, or antibiotics (Rossi & Jennings, 2010, Williams & Willis, 2012). Of note, there is no documented evidence of disease transmission from bed bugs to humans (Lai et al., 2016).


The key to preventing further outbreaks of bed bugs is to recognize the signs of infestation and control the further spread of bed bugs. Tips to prevent and control bed bugs are shown in Table 1.


The elimination of bed bugs is complex and multifaceted.


Washing infested bed linens and clothing in very hot water and drying for 30 minutes in a hot dryer can kill bed bugs.

Bedding Encasements

Using encasements on both the mattress and box springs will trap the bed bugs so they cannot reach the host. Without food, they will die.

Dispose of Infested Items

Wrap the infested items in plastic and label it is infested with bed bugs, so others do not take the item and spread the infestation.


Bed bugs cannot survive when their body temperature is greater than 113[degrees]F. Special equipment that provides dry, convection heating with temperatures greater than 120[degrees]F for several hours can be effective in killing bed bugs. Steam treatments with contact time of approximately 20 seconds per linear foot can kill bed bugs, but only where the steam can reach the bugs.


"Bed bugs can recover from being frozen if not subjected to temperatures low enough or for long enough" (Michigan Department of Community Health, 2010, p. 41), so it is important to adhere to established guidelines when using freezing techniques to reach 0[degrees]F. "Studies have shown that freezing bed bug infested items at less than 0[degrees] F for two or more hours is effective" (Michigan Department of Community Health, 2010, p. 41).


Bug bombs do not kill bed bugs. Chemicals that kill cockroaches will kill bed bugs, but bed bugs are becoming resistant to insecticides. According to the EPA (2016b), there are over 300 registered products in seven categories that will kill bed bugs: Pyrethrins, pyrethroids, dessicants, biochemical, pyrroles, neonicotinoids, and insect growth regulators. The categories and their descriptions are as follows (EPA, 2016b).

Pyrethrins and pyrethroids. Pyrethrins and pyrethroids are the most common pesticides used to kill bed bugs. Pyrethrins are derived from chrysanthemum flowers, and pyrethroids are chemical synthetics that are similar to Pyrethrins.

Dessicants. Dessicants destroy the wax outer coating of the bed bug, causing it to dehydrate and die. Boric acid is an example of a dessicant.

Biochemicals. "Cold pressed neem oil is the only biochemical pesticide registered for use against bed bugs. Cold pressed neem oil is pressed directly from seeds of the Neem tree, a tropical evergreen tree found in Southeast Asia and Africa. The oil contains various compounds that have insecticidal and medicinal properties. It is also used in making products, including shampoos, toothpaste, soaps, and cosmetics. Performance trials conducted at the approved label rates show both products control bed bug adults, nymphs, and eggs" (EPA, 2016b, Biochemicals).

Pyrroles. Chlorfenapyr is the only approved pyrrole for use. It is a pro-insecticide that is dependent on activation to become a new chemical that disrupts the bed bug cell structure, causing it to die.

Neonicotinoids. "Neonicotinoids are synthetic forms of nicotine and act on the nicotinic receptors of the nervous system by causing nerves to fire continually until they fail" (EPA, 2016b, Neonicotinoids).

Insect growth regulators. These growth regulators mimic juvenile growth hormones in insects. They either affect the bed bug's outer hard shell, preventing development into adulthood, or cause the bed bug to develop too rapidly.

Roles of Nephrology Nurses

Nephrology nurses have key support and advocacy roles in preventing and eliminating bed bug infestations.


Nephrology nurses are key to keeping the unit, staff, and patients panic-free. Recognizing signs of an infestation and having an awareness of unit protocol is essential. Nephrology nurses are instrumental in assessing and addressing the psychosocial impact of the bed bug infestation on the patient. Having an awareness of and comfort with anxiety and depression screening tools enable the nurse to assess the psychological burden to the patient.


Many hospitals and healthcare organizations have policies concerning the prevention and elimination of bed bug infestations; however, no guidelines or position statements regarding bed bugs in hemodialysis units were found, nor were any found in nephrology-related organizations, including the Renal Physicians Association, ANNA, or the End-Stage Renal Disease Networks. Nephrology nurses can lead the way for guideline and/or position statement development related to bed bugs, and impact policy at the local, association, and government levels.


Bed bugs are a public health concern that cause significant psychosocial and economic burden to individuals, healthcare facilities, and government agencies. Bed bug infestations can be avoided with diligent patient screening and awareness of signs of infestation. Non-chemical and chemical methods of eradication are effective, if used appropriately. Nephrology nurses play a key role in advocacy, policy/guideline development, and psychological support for patients and coworkers in the prevention and elimination of bed bugs in nephrology settings.

Mary S. Haras, PhD, MBA, MS, APN, NP-C, CNN, is an Associate Professor and the Associate Dean for Graduate Nursing Programs, Saint Xavier University School of Nursing, Chicago, IL; the Chair of ANNA'S Research Committee, and a member of ANNA's Windy City Chapter.

Statement of Disclosure: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

Note: Additional statements of disclosure and instructions for CNE evaluation can be found on page 185.

Exploring the Evidence is a department in the Nephrology Nursing Journal designed to provide a summary of evidence-based research reports related to contemporary nephrology nursing practice issues. Content for this department is provided by members of the ANNA Research Committee. Committee members review the current literature related to a clinical practice topic and provide a summary of the evidence and implications for best practice. Readers are invited to submit questions or topic areas that pertain to evidence-based nephrology practice issues. Address correspondence to: Tamara Kear, Exploring the Evidence Department Editor, ANNA National Office, East Holly Avenue/Box 56. Pitman, NJ 08071-0056; (856) 256-2320; or via e-mail at The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.


Center for Invasive Species Research, University of California, Riverside. (2016). Bedbugs. Riverside CA: Author. Retrieved from

Environmental Protection Agency (EPA). (2016a). Bedbugs: Get them out and keep them out. Washington, DC: Author. Retrieved from

Environmental Protection Agency (EPA). (2016b). Pesticides to control bed bugs. Washington, DC: Author. Retrieved from

Lai, O., Ho, D., Glick, S., & Jagdeo, J. (2016). Bed bugs and possible transmission of human pathogens: A systematic review. Archives in Dermatology Research, 308(8), 531-538. doi: 10.1007/s00403-016-1661-8

Michigan Department of Community Health. (2010). Michigan manualfor the prevention and control of bed bugs. Retrieved from Bed_Bug_Manual_vl_full_reduce_326605_7.pdf

National Pesticide Information Center (NPIC). (n.d.) Bed bug biology and behavior. Corvallis, OR: Author. Retrieved from

National Pest Management Association (NPMA). (2017). 2011 Bugs Without Borders Survey: New data shows bed bug pandemic is growing. Retrieved from -bugs-without-borders-survey-newdata-shows-bed-bug-pandemic-is-growing/

Orkin. (2017). Don't let the bed bugs bite: Orkin releases new top 50 cities list. Atlanta, GA: Author. Retrieved from http://www.

Rossi, L., & Jennings, S. (2010). Bed bugs: A public health problem in need of a collaborative solution. Journal of Environmental Health, 72(8), 34-35.

Thomas, S., Wrobel, M., & Brown, J. (2013). Bedbugs: A primer for the health-system pharmacist. American Journal of Health-System Pharmacy, 70(2), 126-130. doi: 10.2146/ajhp120142

Williams, K., & Willis, M.S. (2012). Bedbugs in the 21st century: The reemergence of an old foe. Lab Medicine, 43(5), 141-148. doi:10.1309/LM1TBJG6S7USSKEN

Caption: Figure 1 Life Cycle of the Bed Bug
Table 1
Top 10 Tips to Prevent or Control Bed Bugs

* Make sure they are bed bugs and not infestation by
other insects.

* Don't panic.

* Consider treatment options.

* Reduce clutter to eliminate hiding places.

* Wash bedding regularly in hot water.

* Freezing may not be reliable.

* High heat methods may not be reliable.

* Label discarded bedding and furniture that contains
bed bugs so others do not take.

* Call in an experienced pest control professional trained
in recognizing and eliminating bed bugs.

Source: EPA, 2016a.

Table 2
Resources for Additional Information about Bed Bugs

Centers for Disease Control and Prevention (CDC) and the Environmental
Protection Agency (EPA)

Developed a joint position statement on bed bug control. Consumers
can contact one of 10 EPA regional contacts for questions related
to their geographical area. The EPA website includes general
information about bed bugs, how to eliminate them, pesticide
information, and a product search tool.

EPA Bedbug Clearinghouse

Offers articles, brochures, checklists, factsheets, manuals,
posters, presentations, videos, and websites.

EPA Bedbug Clearinghouse by Audience

Provides information specific to health centers/hospitals, and
emergency facilities.

The Federal Bed Bug Workgroup Collaborative Strategy on Bed Bugs

Includes technical information, public health and policy action
plans, and was authored by the EPA, CDC, U.S. Department of
Agriculture, and U.S. Department of Housing and Urban Development,
with input from the National Institutes of Health and the
Department of Defense.

Michigan Manual for the Prevention and Control of Bedbugs

A comprehensive guide and reference tool with regulations and laws
specific to the state of Michigan. The information is applicable to
any state, with the exception of the laws and regulations.

National Pesticide Information Center

"The NPIC provides objective, science-based information about
pesticides and pesticide-related topics to enable people to make
informed decisions. NPIC is a cooperative agreement between Oregon
State University and the U.S. Environmental Protection Agency
(cooperative agreement #X8-83560101)."

National Pest Management Association Best Management Practices
for Bed Bugs

University of Nebraska Interactive Bedbug Manual


Enables readers to click on images within the manual for additional
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Title Annotation:Exploring the Evidence
Author:Haras, Mary S.
Publication:Nephrology Nursing Journal
Geographic Code:0DEVE
Date:Mar 1, 2017
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