The main conditions associated with cold and flu, some of which may warrant referral are:

• An acute cough is the main feature of colds and flu. It is not unusual for a cough to persist for three to four weeks and, when severe, is often called acute bronchitis. In most patients there is no need for referral or antibiotics
• Most cases of sore throat resolve within a week, but referral may be necessary if the patient is very unwell or has difficulty swallowing. Patients on chemotherapy, disease-modifying anti-rheumatic drugs and carbimazole should be referred urgently. Those with no cough or cold symptoms are more likely to have bacterial infection so may need referral if they are ill
• Earache is very common with colds and flu in children. In most people this gets better within three days to one week and no treatment other than pain relief is needed. Persistent high temperature, particularly in younger children, may be an indication for referral. Any child who appears especially unwell, infants under two years, or when there is discharge from the ear, merit referral
• Sinusitis is common and usually presents with facial pain and congestion. Toothache and fever may also be present. Symptoms typically last for two to three weeks, and are usually self-limiting, so most cases are treated symptomatically. Those patients with persistent symptoms, rapid deterioration, or who are systemically unwell should be referred. Purulent nasal discharge, particularly if unilateral may also be a reason for referral
• Pneumonia is most commonly associated with flu rather than colds. A productive cough is the major symptom and is usually accompanied by fever, muscle aches, sweats, wheeze, shortness of breath and chest pain. The elderly are more likely to acquire pneumonia and they may also present with weakness, malaise and confusion. Patients with prolonged cough or other conditions such as diabetes, heart disease or those that are old and frail should be referred for further assessment. Patients who are very unwell, or where there are concerns about more serious illness (i.e. pneumonia, pulmonary embolism or cancer), need urgent referral.

There should be a lower threshold to refer to primary care or A&E for those patients who are on immunosuppressants – often for cancer or arthritis, or following a transplant – corticosteroids, or with diabetes. If flu is suspected in these people, early referral may be warranted for assessment and also consideration of anti-viral treatment. Certain clinical signs warrant emergency admission in ill patients. These include a respiratory rate higher than 30 breaths per minute, tachycardia in excess of 130 beats per minute, altered consciousness and significant respiratory effort, particularly if accompanied by exhaustion.