From Clinical guidelines — Diagnosis and treatment manual › Chapter 3: Gastrointestinal disorders · Médecins Sans Frontières, Current online edition, 2026
MSF clinical guidance on diagnosis, rehydration, zinc supplementation and antimicrobial treatment of acute diarrhoea.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition, 2026
- Audience
- Clinicians working in humanitarian and low-resource settings
- Evidence
- Expert consensus based on MSF operational experience
- Reviewed
- 14 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF clinical guideline defines acute diarrhoea as at least 3 liquid stools per day for less than 2 weeks and distinguishes two clinical types: diarrhoea without blood (60% viral, including rotavirus; also bacterial causes such as cholera and enterotoxigenic E. coli) and diarrhoea with blood (50% Shigella, also Campylobacter, E. coli variants, and parasites). The high mortality from diarrhoeal diseases, even benign cases, is due to acute dehydration and malnutrition, which can be prevented by adequate rehydration and nutrition.
The guideline emphasises that treatment centres on prevention and treatment of dehydration through oral rehydration solution (ORS), zinc sulfate supplementation for children under 5 years, prevention of malnutrition by continuing normal diet, and treatment of underlying conditions. Antimicrobials should not be given systematically; they are indicated only for cholera (with antibiotic-sensitivity testing), giardiasis, shigellosis (first-line for bloody diarrhoea), and confirmed amoebiasis. Anti-diarrhoeal drugs and antiemetics are contraindicated.
Prevention strategies include breastfeeding, proper food preparation and storage (avoiding bottle-feeding, ensuring thorough cooking, never storing milk or porridge at room temperature), access to clean water, hand hygiene with soap, and routine rotavirus vaccination in children aged 6 weeks to 24 months in countries with high rotavirus fatality rates.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Acute diarrhoea is defined as at least 3 liquid stools per day for less than 2 weeks
- Zinc sulfate for children under 6 months: 10 mg (½ tablet) once daily for 10 days; children 6 months to 5 years: 20 mg (1 tablet) once daily for 10 days
- Do not systematically administer antimicrobials; only cholera, giardiasis, shigellosis and confirmed amoebiasis require antibiotic or antiparasitic treatment
- Do not administer anti-diarrhoeal drugs or antiemetics
- Continue unrestricted normal diet during illness; in breastfed children increase frequency of feeds (breast milk does not replace ORS)
- In patients over 5 years with severe and rapid onset of dehydration, suspect cholera
- For bloody diarrhoea without laboratory confirmation, treat first-line for shigellosis (most frequent cause at 50%); treat for amoebiasis only if motile Entamoeba histolytica found or shigellosis treatment fails
- Rotavirus vaccination recommended for children 6 weeks to 24 months in countries with high rotavirus diarrhoea fatality rates
Zinc sulfate supplementation in acute diarrhoea
Table extracted from the guideline
| Age group | Dose | Duration |
|---|---|---|
| Children under 6 months | 10 mg (½ tablet) once daily | 10 days |
| Children 6 months to 5 years | 20 mg (1 tablet) once daily | 10 days |
Source: Médecins Sans Frontières, Acute diarrhoea — MSF Clinical guidelines. Reproduced in summary form.
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I recognise that acute diarrhoea continues to burden our primary care services, especially in rural areas where access to clean water remains inconsistent. Georgian clinicians must abandon the widespread practice of prescribing antimicrobials for every diarrhoeal episode and instead focus on oral rehydration and zinc supplementation for children under five. The main implementation challenge will be ensuring reliable zinc sulphate supply at village ambulatories and changing prescribing habits reinforced by patient expectations for antibiotic treatment.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 14 Oct 2026
Applicability
Georgia and the South Caucasus
Acute diarrhoea remains a significant cause of morbidity in Georgia and the South Caucasus, particularly in children under 5 years. Access to oral rehydration solution and zinc supplementation should be ensured at primary health care level. National programmes should assess local rotavirus disease burden to determine vaccination policy priorities. Water quality, sanitation infrastructure and hand hygiene promotion are key preventive measures. Antimicrobial resistance patterns for Shigella and Vibrio cholerae should be monitored locally to guide empirical treatment choices, particularly given regional variations in resistance. Health facilities should ensure that anti-diarrhoeal drugs and antiemetics are not routinely dispensed, as the guideline contraindicates their use.
Questions this guideline answers
Quick answers
Should antibiotics be given routinely for acute diarrhoea?
No. Most acute diarrhoeas are viral and unresponsive to antimicrobials. Antibiotics are beneficial only for cholera, giardiasis, shigellosis (bloody diarrhoea), and confirmed amoebiasis. Systematic antimicrobial use is not recommended.
What is the role of zinc supplementation in children with diarrhoea?
Zinc sulfate given in combination with ORS reduces the duration and severity of diarrhoea and prevents further occurrences in the 2 to 3 months after treatment. Children under 6 months receive 10 mg once daily for 10 days; children 6 months to 5 years receive 20 mg once daily for 10 days.
How should children be fed during an acute diarrhoea episode?
Continue unrestricted normal diet to prevent malnutrition. In breastfed children, increase the frequency of feeds. Breast milk does not replace ORS, which should be given between feeds. Never store milk or porridge at room temperature.
Should I stop breastfeeding during acute diarrhoea episodes?
No, breastfeeding should continue with increased frequency during illness. However, breast milk does not replace oral rehydration solution, which must still be given.
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- Issuer
- Médecins Sans Frontières
- Guideline
- Clinical guidelines — Diagnosis and treatment manual
- Chapter
- Chapter 3: Gastrointestinal disorders
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition, 2026
- Status
- Current
- Published
- 2026-10-14
- Scope
- Diagnosis and treatment of acute diarrhoea in resource-limited settings
- Audience
- Clinicians working in humanitarian and low-resource settings
- Evidence
- Expert consensus based on MSF operational experience
- Record history
- Created 14 Oct 2026 · updated 14 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Acute diarrhoea. In: Clinical guidelines — Diagnosis and treatment manual [Internet]. Paris: MSF; 2026 [cited 2026 Oct 14]. Available from: https://medicalguidelines.msf.org/GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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