Monday 12 May 2014

Acute respiratory infections

(latest update 14 May 2014)
GPs must meet the healthcare needs of a population of patients, not just those who currently succeed in making contact. It is therefore vital that we give colleagues, patients, carers and policy makers the right advice to ensure that those likely to benefit from medical treatment can and do consult us in a timely fashion.

A significant burden of illness in the community is self-limiting, for which treatment by doctors adds little and risks harm.


Acute respiratory infections are extremely common. For example, adults have up to 2-4 colds per year and children up to 121. If every one of a GP’s 2,000 patients attended just 3 times per year with an acute respiratory infection, 6,000 appointments would be needed. This alone would fully occupy a full time GP, who would have to offer 26 appointments per day (assuming 230 working days per year). This would deny anyone the opportunity to consult their GP about any medical concerns for which medical treatment is actually likely to be necessary. Consultation rates are already rising again from a low of 50.2 visits per 1000 person-years in 20042.

Furthermore, 15-30% of patients consult more than once during each acute respiratory infection2. Anecdotally, the first presentation may be within hours of the onset of symptoms and they may additionally consult other healthcare providers such as walk-in centres and Accident and Emergency departments. The urgency and frequency of this demand places the healthcare system under enormous pressure.

Antibiotic prescribing

Presenting to a doctor with a self-limiting acute respiratory infection increases the risk of prescription of antibiotics (often requested by patients when the doctor is unable to reassure them), probably more than any other factor3. This poses risk to the individual patient, who is more likely to experience side effects than benefit, and to the population by encouraging antibiotic resistance.

Overtreatment and illness behaviour

In addition, each prescription for antibiotics encourages friends and family members to attend, and earlier, more frequent attendance in future. Some doctors perceive writing a prescription for an antibiotic to be time-saving: nothing could be further from the truth. For example, of ten people who are prescribed antibiotics for a sore throat, one of them will return within a year with a subsequent sore throat, when they otherwise would not have.4

Even being prepared to negotiate can be dangerous: the gambling industry is testament to the fact that an unpredictable reward can reinforce behaviour more strongly than anything (variable reinforcement operant conditioning)6. Furthermore, the clinician who has appropriately resisted prescribing antibiotics risks a complaint when another clinician is subsequently consulted and acquiesces.

Indeed, if we did have an effective treatment for these illnesses, there would by no means be capacity for GPs to deliver it. This was demonstrated during the 2009 “Swine Flu” pandemic, in which Tamiflu (oseltamivir) was made available in the UK through a national telephone helpline. It has since transpired that the benefits of Tamiflu do not outweigh its risks8. Elaborate isolation measures were also put in place, which, at best, only slowed spread. 

Treatable acute respiratory infections

The number of acute respiratory infections for which medical treatment is essential to avert long term disability or death is small and includes pneumonia, epiglottitis and complications such as quinsy, mastoiditis9, dehydration and sepsis.

Unfortunately, published literature does not yet support the reliable prediction of pneumonia10 and complications of sore throat11 by symptoms and signs alone. We must therefore advise patients to watch out for symptoms suggestive of more severe illness rather than presenting earlier with less specific symptoms (“safety-netting”12).

Symptoms which would merit immediate assessment (“red flag” symptoms) would therefore include:

  • reduced consciousness
  • cold peripheries
  • mottled skin
  • cyanosis
  • anuria
Symptoms strongly suggestive of a need for intervention (“amber flag” symptoms) would include:
  • breathlessness
  • haemoptysis
  • pleuritic chest pain
Less urgent assessment should be considered for symptoms that do not resolve within a timeframe normal for viral illnesses (“green flag” symptoms):
  • cough for more than four weeks
  • earache for more than eight days
  • sore throat for more than seven days13
  • fever for more than five days14
Those that are at highest risk of such complications are the least affluent with the most unmet social needs. This group seem to present readily15. However, if they present without symptoms of the above serious conditions, those that are seriously unwell will be lost amongst the majority with self-limiting illness. Tragically, these will be the first to die.

In reality, the intervention that will have the biggest impact on improving life expectancy, especially in this group, is improving their living conditions. This responsibility must be placed firmly where it belongs: with society and the government.

The remainder of uncomplicated conditions (including acute otitis media, conjunctivitis16 17, pharyngitis, tonsillitis, laryngitis, rhinitis, sinusitis, tracheitis and acute bronchitis18), will resolve spontaneously with no long term sequelae.

This has to be set against the number of medical conditions which are likely to benefit from treatment, such as cancer, heart disease, diabetes mellitus and thyroid disease to name just a few, for which timely access to healthcare professionals is vital: too soon and the symptoms will be too non-specific for targeted investigation; too late and long term complications or reduced life expectancy may be unavoidable.


Desires to improve various health outcomes, whether it be earlier diagnosis of cancer and therefore improved survival or reduce unplanned admission or even reduce infant mortality have been used to justify blanket measures to speed access to healthcare. Unfortunately, these have been implemented without any evidence that they will actually benefit the groups in question, or whether it will actually be even harder for them to compete with those with self-limiting illnesses.

Workforce planning

As the number of GPs is more likely to reduce than increase due to retirement, emigration and insufficient training, it is therefore imperative that patients and their carers (particularly professional carers such as in childcare settings) are confident in diagnosing and managing common acute respiratory infections, with the assistance of community pharmacists.

Health literacy

GPs could support this by setting up training programmes (Ofsted would be well placed to make this obligatory for schools and nurseries). Community volunteers (“Health Champions”19) could help to cascade and support this training. Minor ailments schemes should be commissioned to enable pharmacists to dispense over-the-counter medication for the relief of symptoms free of charge to those exempt from prescription charges.

With these measures in place, consulting healthcare professionals with symptoms of uncomplicated acute respiratory tract infections should be discouraged. Anything which encourages such behaviour, such as prescribing for acute respiratory tract infections should also be discouraged.

Opportunity gain

If we can significantly reduce attendance for acute respiratory tract infections, the opportunity gain will be immense, allowing patients with medical conditions which are likely to benefit from medical treatment much better access to their doctors.


Further work

  • Systematic review of the literature focussing on predictive value of symptoms
  • Evidence to guide safety netting

For Local Authorities

  • Community Health Champion schemes
  • Housing

For National government

  • Accept responsibility for life expectancy (a societal/economic, not a healthcare issue)
  • Understand that access to healthcare must be targeted to exclude self-limiting illnesses


  • Endorse this document
  • Accredit training in diagnosing and managing common self-limiting illness for nursery and school staff

For Ofsted

  • Ensure one member of staff with self-limiting illness training at each nursery and school is on duty at all times

For CCGs

  • Commission minor ailments schemes

For GPs and other healthcare professionals

  • Address prescribing for self-limiting illness - possible audit area.

Symptom summary

Red flags

(consider urgent assessment for immediate treatment or admission)
  • reduced consciousness
  • cold peripheries
  • mottled skin
  • cyanosis
  • anuria

Amber flags

(consider assessment for treatment; urgency depends upon severity)
  • more difficulty breathing than usual
  • haemoptysis
  • pleuritic chest pain

Green flags

(symptoms typical of self-limiting respiratory infections; consider assessment for treatment if last longer than normal)
  • cough for up to four weeks
  • earache for up to eight days
  • sore throat for up to seven days
  • fever for up to one week

Yellow flags

(factors known to increase consultation and therefore antibiotic treatment for self-limiting respiratory infections)
  • previous treatment of patient for respiratory infection
  • treatment of contact for respiratory infection

Black flags

(features not covered by this review)
  • Any symptom not mentioned here
  • COPD
  • Bronchiectasis


1Colin Tidy (2012). Upper Respiratory Infections - Coryza | Doctor | Retrieved April 6, 2014, from
2Stanton N, Francis NA, Butler CC. Reducing uncertainty in managing respiratory tract infections in primary care. Br J Gen Pract 2010;60:e466–75. doi:10.3399/bjgp10X544104
3Fleming DM, Ross AM, Cross KW, et al. The reducing incidence of respiratory tract infection and its relation to antibiotic prescribing. Br J Gen Pract 2003;53:778–83
4Marshall T. Reducing unnecessary consultation - a case of NNNT? Bandolier 1997;44-4
5Kendall SB. Preference for intermittent reinforcement. J Exp Anal Behav 1974;21:463–73. doi:10.1901/jeab.1974.21-463
6Sparkman RB. The Art of Manipulation. Knopf Doubleday Publishing Group 1979
7Michiels B, Van Puyenbroeck K, Verhoeven V, et al. The value of neuraminidase inhibitors for the prevention and treatment of seasonal influenza: a systematic review of systematic reviews. PLoS One 2013;8:e60348. doi:10.1371/journal.pone.0060348
8Jefferson T, Jones MA, Doshi P, et al. Regulatory information on trials of oseltamivir (Tamiflu) and zanamivir (Relenza) for influenza in adults and children. 2014. (accessed 11 Apr 2014)
9NICE. CG69 Respiratory tract infections: NICE guideline. 2008
10Stanton N, Francis NA, Butler CC. Reducing uncertainty in managing respiratory tract infections in primary care. Br J Gen Pract 2010;60:e466–75. doi:10.3399/bjgp10X544104
11Little P, Stuart B, Hobbs FDR, et al. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ 2013;347:f6867. doi:10.1136/bmj.f6867
12Neighbour R. The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style. Radcliffe Publishing 2005
13Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013;347:f7027. doi:10.1136/bmj.f7027
14NICE. CG160 Feverish illness in children: NICE guideline. 2013
15Carr-Hill RA, Rice N, Roland M. Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices. BMJ 1996;312:1008–12. doi:10.1136/bmj.312.7037.1008
16Rose P. Management strategies for acute infective conjunctivitis in primary care: a systematic review. Expert Opin Pharmacother 2007;8:1903–21. doi:10.1517/14656566.8.12.1903
17Sheikh A, Hurwitz B. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane database Syst Rev 2006;:CD001211. doi:10.1002/14651858.CD001211.pub2
18Little P, Stuart B, Moore M, et al. Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis 2013;13:123–9. doi:10.1016/S1473-3099(12)70300-6
19Altogether Better. Health Champions. 2014. (accessed 6 Apr 2014)

No comments: