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, due to possible impairment of their immune system brought about by intravenous drug use. (1)

At least one study isolated an endotoxin produced by this Enterobacter 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. These 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 fourteen years.

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. Bourgois, Phillippe; Schonberg, Jeff; Righteous Dopefiend,(Berkeley, California, University of California Press, 2009) pp8-9, 83-84.

8 responses to this post.

  1. It’s interesting you mentioned the FA specifying dilaudid as one that didn’t require filters. I specifically remember the K4’s from back in the day (I think they’ve since reformulated them) being one of the few pills that we could “cold shake.” That basically means we could crush them up, pour them into the top of the syringe and then pull water up into the syringe with the crushed up pills and then “shake it” (“Cold shake” = just shake it up in cold water)… It would nearly totally dissolve and then the entire thing could be injected. But Cotton Fever certainly isn’t any fun. I’ve seen several people even get the “shakes” – borderline convulsions with the appearance of minor seizures – from cotton fever and/or dirty shots. Thank goodness for methadone (and buprenorphine), that’s all I have to say! 🙂

    Zac Talbott


  2. Had my share of those, feels like the worst thing in the world for about 1 hours. I don’t know what is worst one hour of cotton fever, or one hours of the worst withdrawl symptoms I’ve ever had.


  3. By the way, it is not only cotton fibers I have rarely use them. Mine came from pieces of cigarette filters. My hat comes off for you again, great informative article. I did not know much of what you informed us about this here cotton fever.

    If I ever refute anything you say, please note that I do not do it from any mean-spirited attitude. The Gods know I got plenty of that from 12 Stepping facilitators who claims to be working on my own best interest but forgot there is a code of ethics that they most fallow.


  4. Oh forgot to tell you too, that a lot of the syringe exchange programs I know do provide clean cottons itty bitty pieces for people to use. They give you a bag with what I suppose are sterilized cotton.


    • I’m glad to hear that. It makes good sense – some scientists say it’s older, re-used cotton that’s more likely to cause cotton fever. Glad they are distributing new sterilized cotton.


  5. I been sick for da ys and i tthink i have cotton fever i fellblike im going die cant sat up or do anything my head hurts anyone know wants wrong


  6. H out w i know i have cotton fevervif i dont use cotton


  7. How do i know i have cotton fever if i don’t v use Cotton i been sick n thaw up n cant get up dobt know whats wrong


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