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Updated on May 16, 2022

Cotton Fever

What is Cotton Fever?

Cotton fever, sometimes called a “dirty shot,” is a term used to describe a medical condition that affects long-term methamphetamine and heroin addicts. It is caused by Pantoea agglomerans, a bacteria found in cotton plants. 

Here are the steps to contract it:

  1. The bacteria releases endotoxins before the cotton plant is processed 
  2. The drug user filters the drugs through cotton balls before injecting them
  3. The user injects the drug
  4. The endotoxins enter the human body upon injection
  5. Benign febrile syndrome develops

Cotton fever can occur due to an inflammatory blood infection (sepsis) caused by using a syringe multiple times to inject drugs. 

Sepsis occurs when bacteria enter the bloodstream and the body. It launches an immune response to fight off the invader. Sepsis is potentially fatal.

Initially, healthcare professionals believed cotton fever happens because small fragments from the cotton balls get into the bloodstream during injection. To this day, some drug users mistakenly believe fragments and debris cause cotton fever. 

How Does Someone Get Cotton Fever?

People get cotton fever when they use dirty needles or cotton when injecting IV drugs. The best way to avoid getting cotton fever is to only use clean needles one time for intravenous drug use. 

If someone must reuse a needle, it can be sterilized by heating it to kill any bacteria. However, doing this doesn’t guarantee infection won’t occur. 

Using cotton puts you at risk of infection, even when using a clean needle. Preventing cotton fever that comes from using cotton in the injecting process is more of a challenge. 

Attempts by intravenous drug users to sterilize cotton can make the fibers toxic, creating a secondary and potentially fatal risk. In some cases, trying to sterilize cotton for drug use can lead to untreatable infections.

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What are the Symptoms of Cotton Fever?

Symptoms of cotton fever arise within a few minutes or up to 12 hours after an injection. 

The symptoms may include:

  • Fever
  • Tachycardia (fast heartbeat)
  • Abdominal pain
  • Nausea
  • Vomiting
  • Chills
  • Leukocytosis (elevated white blood cell count)
  • Headache
  • Shortness of breath
  • Muscle pain
  • Mild distress

Cotton fever is one of the greatest risks IV drug users face. 

Injecting drugs also has many other risks, including collapsed veins, blood clots, and other conditions, none of which are pleasant. These risks increase when intravenous drug users inject a drug with a previously used needle.

Drug users who have developed cotton fever describe it as one of the worst experiences they’ve ever had, even compared to withdrawal.

Cotton fever typically develops within 30 minutes after injection. However, symptoms can arise sooner. 

Symptoms such as intense muscle spasms and bone aches are usually followed by severe cold and flu symptoms, migraines, and shaking. 

Nausea and vomiting are also common for intravenous drug users who develop cotton fever. 

Usually, these symptoms last several hours, even up to 24 hours. Cotton fever requires immediate medical attention. 

Can You Die From Cotton Fever? 

Yes, cotton fever may be fatal. This is especially true for patients who do not receive the appropriate medical attention in response to the life-threatening illness. 

Any IV drug injection puts you at risk. But using a dirty needle or incorporating cotton used to filter the drug into the process increases this risk.

In some cases, cotton fever is a challenging diagnosis. The flu-like symptoms mimic a variety of other conditions and illnesses. Patients suspected of having cotton fever might be checked for other infectious diseases or infections. Then the symptoms are treated. 

There is no “cure” for cotton fever, and any medicine given to patients is to alleviate specific symptoms. 

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How to Get Rid of Cotton Fever (Best Treatments) 

Treatment is available for cotton fever. 

In most cases, the condition eases on its own. Treatment can help reduce symptoms and the risks associated with the condition. 

It’s important to make sure that other infections aren’t causing similar symptoms. The fast onset of symptoms after injection typically indicates cotton fever, as opposed to other types of infections. 

The sooner you seek medical attention once symptoms arise, the better your prognosis will be.

The best “treatment” for cotton fever is avoiding it in the first place. Intravenous drug users can do this by getting clean. Many people fear the process of getting clean because of the symptoms of withdrawal. 

However, most people who have experienced both and can compare cotton fever to withdrawal describe cotton fever as much worse. Some even assure people with SUD that if they can survive cotton fever, they’ll get through withdrawal. 

Having an infection in your bloodstream affects your entire body. Medical attention eases some of the symptoms of cotton fever, but there is still pain. The patient rarely feels better until the infection clears.

If detox and sobriety aren’t an option yet for you, the best way to avoid cotton fever is to only use clean needles one time to inject drugs. 

The most common treatment for cotton fever focuses on decreasing a person’s fever. In most cases, high fevers resolve within a few hours or a day. However, you can speed the process by soaking in a long bath and using fever-reducing medications. 

Antibiotics are used in extreme or long-lasting cases of cotton fever. 

Other Side Effects & Risks of Injecting Drugs

In addition to the risk of cotton fever, other potential side effects and risks of using IV drugs include:

  • HIV/AIDS: A virus that develops into a disease that attacks the body’s immune system
  • Hepatitis: An infection or disease that causes swelling in the liver
  • Infective endocarditis: An infection caused by fungi or bacteria entering the bloodstream and traveling to the heart

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Treatment Options for IV Drug Use 

Treatment for IV drug use varies from person to person. The best treatment plans are tailored to the specific person’s needs. Treatment options might include:

  • Outpatient programs
  • Residential programs
  • Counseling, including talk therapy and behavioral therapy
  • Peer support
  • Medication-assisted therapy (MAT) to curb cravings and reduce withdrawal symptoms
  • 12-step programs
  • Relapse prevention and support
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  1. Zerr, Ashley Michelle, et al. “Cotton Fever: A Condition Self-Diagnosed by IV Drug Users.” The Journal of the American Board of Family Medicine, vol. 29, no. 2, 1 Mar. 2016, pp. 276–279.
  2. National Institute on Drug Abuse. “Treatment Information.” National Institute on Drug Abuse.
  3. Ho, J., et al. “Safe and Successful Treatment of Intravenous Drug Users with a Peripherally Inserted Central Catheter in an Outpatient Parenteral Antibiotic Treatment Service.” Journal of Antimicrobial Chemotherapy, vol. 65, no. 12, 23 Sept. 2010, pp. 2641–2644, 10.1093/jac/dkq355. 
  4. Cotton Fever: An Evanescent Process Mimicking Sepsis in an Intravenous Drug Abuser.” Hospital Medicine Virtual Journal Club, 6 Nov. 2013.
  5. Francis, Munib J., et al. “Cotton Fever Resulting in Enterobacter Asburiae Endocarditis.” IDCases, vol. 19, 2020, p. e00688, 10.1016/j.idcr.2019.e00688
  6. Downtown Needle Exchange. “Cotton Facts and Tips.” Public Health Seattle and King County.

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