Updated on April 3, 2024
5 min read

Cotton Fever: Symptoms, Toxic Syndrome, & More

What is Cotton Fever?

Cotton fever, or “dirty shot,” is a condition that affects long-term methamphetamine and heroin addicts. It's caused by Pantoea agglomerans, a bacteria found in cotton plants.

As a benign syndrome, it's not life-threatening. However, without immediate medical attention, it can be.

Here’s how cotton fever is contracted: 

  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

When Do Cotton Fever Symptoms Occur?

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

Symptoms typically last 6 to 12 hours. In serious cases, they can last as long as 2 days. When symptoms occur, call for emergency help quickly.

What are the Symptoms of Cotton Fever?

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

Common symptoms include:

  • Fever
  • Tachycardia (fast heartbeat)
  • Abdominal pain
  • Nausea
  • Vomiting
  • Chills
  • Leukocytosis (elevated white blood cell count)
  • Headache
  • Shortness of breath
  • Muscle pain
  • Mild distress
  • Bone aches
  • Severe cold and flu-like symptoms

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

Injecting drugs also has many other risks. Collapsed veins, blood clots, and other conditions, to name a few. 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.


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What Causes Cotton Fever?

There are two potential causes of cotton fever:

1. Injection 

People get cotton fever when they use dirty needles or cotton when injecting IV drugs. 

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

Attempts by intravenous drug users to sterilize cotton can make the fibers toxic. This creates a secondary and potentially fatal risk. Sometimes, trying to sterilize cotton for drug use can lead to untreatable infections.

2. Sepsis 

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

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

Initially, healthcare professionals believed cotton fever happens because of small fragments. They thought fragments from cotton balls got into the bloodstream during the injection. Some drug users mistakenly believe fragments and debris cause cotton fever.

Can You Die From Cotton Fever? 

Yes, cotton fever can be fatal. This is especially true for those who do not receive the appropriate medical attention.

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

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

Keep in mind: There is no “cure” for cotton fever. Any medicine given is to help alleviate specific symptoms.

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How to Get Rid of Cotton Fever (Best Treatments) 

In most cases, the condition eases on its own. However, there are a few ways to help eliminate cotton fever.

Medical Treatment

If you seek medical attention, treatment for cotton fever is available. Treatment can help reduce symptoms and the risks associated with the condition.

It’s important to ensure other infections aren’t causing similar symptoms. Unlike other types of infections, the fast onset of symptoms after injection typically indicates cotton fever. 

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


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 describe cotton fever as much worse. Some even assure people with SUD will get through withdrawal if they can survive cotton fever. 

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.

Avoid Reusing Needles

If detox and sobriety aren’t options, only use clean needles once to inject drugs. This is the best way to avoid contracting cotton fever.

If you need to reuse a needle, it can be sterilized with heat to kill bacteria. However, doing this doesn’t guarantee an infection won’t occur.

At Home Remedies and Antibiotics

The most common treatment for cotton fever is decreasing the 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

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:

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Updated on April 3, 2024
6 sources cited
Updated on April 3, 2024
  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, 1 Mar. 2016.

  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, 23 Sept. 2010.

  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.” ID Cases, vol. 19, 2020.

  6. Downtown Needle Exchange. “Cotton Facts and Tips.” Public Health Seattle and King County.

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