Cotton Fever

An addict still using heroin recently asked me what “cotton fever” was, and how he could tell if he was sick with it.

 Cotton fever is caused by bacteria commonly found on cotton plants, initially named Enterobacter agglomerans, later changed to Pantoea agglomerans. Most intravenous drug addicts filter heroin through cotton filters, to remove particles that could clog both their injection needle and their veins. Sometimes fibers of cotton break off from the filter, carrying the bacteria with it. These bacteria in the bloodstream cause fever and chills, but in a healthy person, this usually resolves on its own. It’s rare to see it cause serious infection. However, doctors still recommend addicts with cotton fever seek medical care and receive appropriate antibiotics. (1)

At least one study isolated an endotoxin produced by this bacteria, so it’s possible that the fever is actually caused by this toxin, released from the bacteria, and not from an actual infection.

 Enterobacter species, while found in feces of both animals and humans, are also found in the plant world. Usually, these bacteria aren’t a particularly vicious, which is why they rarely cause sepsis (overwhelming infection) unless the individual has an impaired ability to fight infection. In the 1970’s, some medical products (blood, IV fluids) were found to be infected with this species, and caused significant infections, but this was probably due to a large amount of the bacteria infused into patients.

 Cotton filters become more fragile with use, so addicts using new filters probably have a lower risk of cotton fever. After cotton filters are used, they remain moist and can become colonized with all sorts of bacteria, especially if they are kept warm, as happens when they are stored in a pocket, close to the body. This bacteria can cause infection when injected. Cotton filters can transmit hepatitis C and possibly other infections, if they are shared with other drug users. (2)

 Filters also retain some of the injected drug, making them of some value in the world of intravenous addicts. It’s considered a gesture of generosity to offer another addict your “cottons” because the addict will get some small amount of the drug. (3)

 Even in view of all of the above, it’s still better to use a filter than to use unfiltered heroin. A new cotton cigarette filter has been shown to remove up to 80% of particulates in heroin, and reduces the risk of thrombosis of the vein from particles. Other makeshift filters are made from clothing, cotton balls, and even tissue paper.

 Syringe filters are manufactured for medical and laboratory use. They can be designed to filter particles down to 5 micrometers. Besides being more expensive and difficult to obtain, studies show these filters retain more of the drug than other makeshift filters, making them less desirable to some addicts. (2)

 Cotton fever itself usually isn’t fatal. The biggest challenge is knowing if the addict has cotton fever or something worse, like sepsis. Sepsis is an infection of the blood stream, and even heart valves can become infected, causing serious and life-threatening problems. 

I asked a former IV drug addict about his experience with cotton fever.

 Me: What does cotton fever feel like?

 Former Addict: You get a fever that kind of feels like withdrawal. You know there’s something bad wrong, and you don’t know what to do about it. I’ve laid on the floor and thought I was going to die. A lot of times people get it when they’re rinsing, and that means they’re coming down anyway. When the dope got short and I was rinsing cottons, that’s when I got it.

 Me: How long does it last?

 FA: It seems like it lasts a long time, but the intensity is bad maybe an hour or two. You shake, you sweat; it feels just like the flu.

 Me: Ever go to the hospital with cotton fever?

 FA: No, no! (said emphatically) I was usually wanted by the police. Only time I went to the hospital is with severe trauma.

Me: I don’t understand what you mean by rinsing.

 FA: Rinsing’s when you squeeze that last little bit of drug out of the cotton [filter]. You rinse the spoon and cotton with a little water. I would save all my cottons. That was my rathole for when the dope ran out. I would actually load the cottons into the barrel of a syringe then draw water in to the barrel of syringe, then squeeze until they were bone dry. I squirted that on to a spoon, and used a new cotton to draw that into a syringe.

 Me: Why do you use cotton filters? Do you use it with every drug you injected?

 FA: I used cotton to strain any dirt that may be in the product, that might get up in the syringe. I didn’t want no dirt. Didn’t have to be cotton. [If you don’t use a filter, you] shoot a bunch of trash up in yourself, and get trash fever.

 I used an itty bitty cotton. Some people would use a quarter of cigarette butt. That was wasteful to me. It got too saturated, could hold too much residue, or dope.

 I didn’t have to use cotton with quarter gram morphine or Dilaudid. Not enough trash to stop it up. If there’s trash in the syringe, I used a cotton.

 Thankfully, this person has been in recovery from addiction for more than thirteen years. When I asked him how he was able to stop, he said Narcotics Anonymous meetings.

 Recovery is the best way to avoid cotton fever. You never have to go through that again.

  1. Rollinton, F; Feeney, C; Chirurgi, V; Enterobacter agglomerans-Associated Cotton Fever,  Annals of Internal Medicine 1993; 153(20): 2381-2382.
  2. Pates, R; McBride, A; Arnold, K; Injecting Illicit Drugs, (Oxford, UK, Blackwell Publishing, 2005) pp. 41-43.
  3. 3.       Bourgois, Phillippe; Schonberg, Jeff; Righteous Dopefiend,(Berkeley, California, University of California Press, 2009) pp8-9, 83-84.

10 responses to this post.

  1. Posted by bizzyBone on December 15, 2011 at 9:29 am

    does cotton fever turn into a deadlier for called sepis or sepsis ???! and how long if goes untreated n unknowen


    • Some people think that’s all cotton fever is – bacteria released into the blood stream from the cotton, but others believe it’s a more complex reaction to bacteria in the cotton.
      But yes, cotton fever can turn into sepsis. Some specialists say every episode of cotton fever should be treated aggressively with antibiotics to prevent death. Untreated sepsis is often fatal, yes, though I don’t know percentages.
      Sepsis is another reason why intravenous drug users die at such higher rates than age-matched non-IV drug users.


  2. Posted by enagreen on November 9, 2012 at 1:30 pm

    the other night i did a shot and the nextt thing i knew my wds felt worse and my heart was pounding and i started pukinng.. the next day was prety bad but worst of all was the pounding heart.that werid shot was 10ish pm on nov 7th and today is nov 9th around hearts stiill pounding.whats going on?


  3. Posted by Brittney on November 12, 2013 at 1:02 pm



    • I don’t know what’s wrong – you need to go to the nearest hospital emergency room. You could have bacteremia, where bacteria on your skin went into your bloodstream to cause an overwhelming infection. Please go now!
      I’m assuming you are saying this is unlike your usual opioid withdrawal. Even if it is…I wouldn’t assume that’s it’s not something worse. Go get checked out.


  4. I’ve had trash fever on more than three occasions. As soon as I shot up, maybe Ten minutes went by and suddenly my hands (esp the finger tips ) were so cold lthought I would die. Then I became cold allover & it was 85 degrees that day.! I was sitting in the car in my inlaws driveway and miserable. Finally, my fiancé came out and I told him to take me back to our apt. He had no idea what was wrong . Was out of my head and so very cold I couldn’t wait to get my 2 big converters on me & lie down !! He gave me a clinking and Bch long I went to sleep & woke up much better. A bit weak but better than two hours earlier. It was from a old , cotton his brother ” Swore ” to me was good. That bastard pulled that cotton crap one other time on. me. Anyway, keep things clean. alcohol, distilled water and NO slick feeling cottons.. wash your hands damn good. Have someone you trust ( I know that can be a tuffy.)around you.


  5. Posted by Violet on September 1, 2022 at 2:43 am

    I have been searching all over the internet about “Pantoea agglomerans” and cotton fever and like 100 different ways of bacteria and safe IV-ing just trying to figure out one thing and I still can’t seem to find a answer!!!
    My question is, is there a specific way that I can clean/cook out/purify that bacteria on a used dope cotton, so that if somebody wanted to re-use a dope cotton that they for example have had sitting in a little tiny glass jar for like 1-2 days, because they are out of money and dope and the cotton still has a heavy amount of dope on the say cotton, but they wanted to ensure that they won’t get sick from the bacteria that has grown on it after re-using it. Is there a way to purify and clean that cotton or clean the shot you drew up in your needle from the cotton by cooking it or squirting out your shot of dope into a new clean cap, and re filtering it a second time, again using a now brand new clean and fresh cotton after having already pulling up the dope with the old cotton first and then the new cotton afterwards, or cooking the shot on a spoon with fire to sterilize the bacteria away, or maybe using another safe liquid instead of water like (yes it sounds dumb but it’s just a example) like say coca-cola because the acidic maybe kills the bacteria or something? Or is this just a matter of, you take a chance and hope it doesn’t give you cotton fever, or don’t do it at all because there is no way to dissenfect the bacteria away to purify your shot and eliminate any bacteria or chance of cotton fever happening??


    • I don’t think there’s any way to be sure cotton fever won’t occur, though filtering with a second cotton may reduce the risk. There’s no data about this, though.


      • Posted by Emily on September 16, 2022 at 3:31 am

        Hmmm…well. I know cooking it can help too I think? But I suppose I can try one of the old cake batter cottons I have from almost a month ago and filter it 2 times afterwards and then cooking it, and I will try… you know..for the sake of science… Totally kidding. Sadly unless multiple people try to do that with old cake batter cottons, and report what happens despite weather or not they get sick….I think this might be a thing where no matter how many times and how many people try it to prove or disprove this method of making sure cotton fever doesn’t happen….. It still can’t be 100% data that can or can’t be proved. I feel as though every body is different, some of our bodys fight things better than others, some don’t…and even if they made say 100 cottons with the same amount on each one and left them in a glass jar for say a month and then tried methods of filtering it, each person’s body is unique and will most likely have a different response and effect to it. So I don’t know if there is any true way to make clear data. It would still be rolling Dice no matter what….

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