Using and sharing injection equipment can cause serious injury and death.
Using and sharing injection equipment is an extremely high-risk activity and is never truly safe to do in a non-medical context. This guide is provided for educational and harm reduction purposes only and we strongly discourage users from engaging in this activity.
Cotton fever refers to the set of physical symptoms experienced after a substance has been filtered and injected. Cotton fever can happen with unused cotton filters and filters of other material, but happens much more commonly as a result of the practice of saving and soaking old cotton filters. While this is a risk among any group of intravenous substance users, it is most commonly reported among intravenous heroin users.
The risk of disease comes from cotton plants that have been heavily colonized by a strain of bacteria known as E. Agglomerans. This bacterium wreaks havoc in the respiratory system of the body which causes the symptoms of cotton fever. While even using a new cotton filter puts one at risk for cotton fever, these risks only become increased when old filters are rehydrated and reinjected.
The primary risk factors for cotton fever are:
- Injection drug use - Injection drug use is the underlying cause of "cotton fever". Injection drug users often use cotton balls or other cotton products to filter the substance-containing solution. This solution passes through the filter to be injected before it enters the body. Upon injection, cotton fibers and bacteria present in the cotton filter enter the bloodstream directly. Even though a filter does prevent some particles and unwanted material from directly entering the body, it can still introduce dangerous bacteria and contribute to the risk of infections greatly.
- Reusing cotton filters - During the injection process, a minute amount of a substance becomes left within a filter. The practice of saving up these filters to produce an active dose of the substance is a cause of cotton fever and the bodily harm and death that can result from it. Some users save these cotton balls for extended periods of time and then later soak them in water to extract any residual material. This practice is very dangerous as it introduces both insoluble particles as well as bacteria into the blood stream. When the cotton filters of previous injection solutions are saved, rehydrated, and reinjected the injection process is made more unsanitary by the introduction of bacteria that have been multiplying within the cotton filter.
- Improper storage of cotton filters - When the saved cottons are stored while they are still damp or placed/stored in a damp environment, it creates an ideal environment for the dangerous bacteria to multiply, vastly increasing users' susceptibility to cotton fever. While the saving of cotton filters for reuse should not be done at all under any circumstances, as stated above, users determined to do so can mitigate the risk by assuring any cottons are dry before storage and stored in an airtight dry environment.
- Unsanitary environment or materials - If materials that have been shared communally are used, the probability of contracting cotton fever becomes increased. If injection materials are re-used, unclean, or left out in the open before their first use, the risk of bacterial infection becomes increased simply due to the environment. The utmost care and caution should be taken to ensure the most sanitary conditions possible before any injection drug use.
- Using filters unfit for injection - A way to minimize the risks that result from using cotton filters is to use filters made specifically for injection drug use. These specially designed filters will filter out particles over 10 microns, which is the standard of the European Pharmacopeia. The use of cotton filters, or cigarette filters, can lead to insoluble particles entering the bloodstream and causing internal sepsis, or potentially life-threatening blood poisoning. These specially made filters, the Compet AG syringe filter (Compet AG, Switzerland), the "filter syringe" (Frontier Medical Group, UK) and the Sterifilt® (Apothicom, France), are not yet readily available for all injection drug users.
Cotton fever can be prevented by:
- Completely avoiding the use of cotton filters. Micron filters are a safer alternative to cotton filters and filter out more impurities than their cotton counterparts. A detailed guide on how to use micron filters can be found on Drugs Forum Micron Filter Guide. The use of micron filters and other non-cotton filters does not eliminate the chance of acquiring cotton fever, but it does eliminate the possibility of cotton fibers and cotton-specific bacterium entering the blood stream and causing internal sepsis.
- Avoiding the collection and soaking of used cotton filters to extract any residual product. This puts one at a substantially increased risk of acquiring cotton fever. Old cotton filters can harbor bacteria and pathogens in addition to any remaining substance residue.
- Avoiding the reuse of spoons, filters, and needles of other substance users. This can lead to an increase in the risk of transmitting viral diseases and bacterial infections.
Symptoms and treatment
The initial symptoms of cotton fever often present themselves immediately upon injection, but may take over an hour to fully manifest. They most often appear within one half hour to a few hours following injection. If the symptoms become immediately present, the user should take a fever-reducing medication (Ibuprofen, Naproxen) and do their best to relax to alleviate them. In most cases, the symptoms will subside on their own within a day. However, if symptoms such as increased heart rate, fever, and nausea continue to progress it is imperative that medical attention is sought immediately.
Cotton fever can present itself in many ways; it often resembles the symptoms of sepsis or tissue infection, which requires immediate medical attention and "cotton fever" (which can be caused by many different factors) presents a host of symptoms. If any of the symptoms listed below become apparent in an injection drug user, especially one that saves and reuses their filters, the individual should be taken to an emergency medical care center as soon as possible:
- Fever - The fever may worsen to the point that it becomes potentially fatal. This may manifest as a hot fever or cold chills. If an extended high temperature is observed the individual should receive medical care immediately. The high fever caused by the bacterium can become fatal if medical attention is not received immediately.
- Muscle cramps
- Muscle spasms
- Stomach cramps
- Muscle contractions
- Muscle tremors
- Physical fatigue
- Increased heart rate
If one experiences any of the above-mentioned side effects, especially fever, muscle cramps, muscle spasms, and stomach cramps, it is imperative to seek medical attention immediately to avoid bodily harm and death. It is also imperative that the user stops injection drug use immediately as this could lead to further bodily harm. As the outcomes of cotton fever can range from harmless to deadly, it is important to be vigilant and monitor the progression of the illness. While relaxation and taking anti-fever medications can be a suitable treatment for relatively mild symptoms that subside quickly, it is not an adequate course of action for severe cases of cotton fever that persist and worsen as time goes on.
Cotton fever is a bacterial disease that enters the bloodstream through filtering a solution for intravenous drug use. Cotton fever is a condition that is often associated with the use of cotton to filters to filter injectable substances such as heroin, methamphetamine, and cocaine. When used as a filter for injection drug use, cotton fibers and bacteria can enter the injection solution and thus enter the bloodstream where they cause a host of negative physical side effects including sepsis.
It has been established that the condition derives from an endotoxin released by the bacteria Pantoea agglomerans which colonizes cotton plants and not from the cotton itself. A condition very similar to cotton fever was described in the early 1940s among cotton farm workers. The existence of this specific strain of bacteria and history of similar symptoms makes common cotton products, such as cotton balls or q-tips, unsafe for use as injection filters.
The term cotton fever was coined in 1975 after the syndrome was recognized in intravenous drug users. However, some sources have attributed the symptoms of cotton fever with sepsis characterized by unsafe and unsanitary drug injection practices, many of which can be avoided by using clean or new injection supplies upon each injection. The peculiar fact that cotton fever-like symptoms have been observed in injection drug users that use various filter materials highlights the uncertainty surrounding this infection. Injection drug users should always use clean filters, preferably micron filters, that are specifically designed for injection. Materials such as cigarette filters, cloth, or scented cotton products may introduce other infection risks upon injection and should likewise be avoided.
- Torka, P., & Gill, S. (2013). Cotton fever: an evanescent process mimicking sepsis in an intravenous drug abuser. The Journal of Emergency Medicine, 44(6), e385-e387. http://dx.doi.org/10.1016/j.jemermed.2012.11.090
- “Cotton fever” in narcotic addicts, MD Thomas Shragg http://www.sciencedirect.com/science/article/pii/S0361112478803396?via%3Dihub
- "The filter of choice: filtration method preference among injecting drug users" Published online 2011 Aug 22. doi: 10.1186/1477-7517-8-20 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3176466/
- Cotton Fever - How to Avoid and Deal with Cotton Fever - Heroin Helper. (2004, January 10). Retrieved from http://web.archive.org/web/20170224005638/http://www.heroinhelper.com/user/health/cotton_fever.shtml
- HCV Advocate Cotton Fever Fact Sheet http://hcvadvocate.org/hepatitis/factsheets_pdf/HarmReduction/Cotton_Fever.pdf
- "What Is Cotton Fever and Why Is It So Dangerous?" https://www.drugtreatmentcenterfinder.com/cotton-fever/
- Harrison, D. W., & Walls, R. M. (1990). “Cotton fever”: A benign febrile syndrome in intravenous drug abusers. The Journal of Emergency Medicine, 8(2), 135-139. PMID: 2362114
- R. Ferguson, C. Feeney, and V. A. Chirurgi, "Enterobacter agglomerans--associated with cotton fever", Archives of Internal Medicine, October 25, 1993, pp. 2381-2382.