Consider referring a patient with cholera for specialist care or hospitalization if they show signs of clinical dehydration or shock, or if they have red flag symptoms such as altered responsiveness, decreased urine output, pale or mottled skin, cold extremities, sunken eyes, tachycardia, tachypnoea, weak peripheral pulses, prolonged capillary refill time, reduced skin turgor, or hypotension. These signs indicate moderate to severe dehydration or shock requiring urgent intravenous fluid therapy and specialist management.
Also refer patients who persistently vomit oral rehydration solution (ORS) or who deteriorate despite oral rehydration therapy, as they may need intravenous fluids and close monitoring.
Children or patients at high risk of dehydration (e.g., very young age, malnutrition, immunocompromise) or with social circumstances that make remote assessment unreliable should also be referred for face-to-face assessment or specialist care.
Seek urgent expert advice if intravenous fluid therapy is required, especially in cases of hypernatraemic dehydration, and consider paediatric intensive care consultation if shock persists after initial fluid resuscitation.
Antibiotic treatment should be given in confirmed cholera cases, and specialist advice sought for antibiotic management, particularly if the patient has recently travelled abroad.
Overall, referral is warranted when dehydration is moderate to severe, shock is suspected or confirmed, oral rehydration fails, or there are red flag clinical features indicating serious illness.
NICE CG84