From the Guidelines
Nystatin should be administered as 400,000-600,000 U/mL (4-6 mL four times daily) or 1-2 flavored 200,000 U pastilles 4-5 times daily for 7-14 days for the treatment of oral candidiasis. This recommendation is based on the guidelines from the Infectious Diseases Society of America, as outlined in the 2009 update for the management of candidiasis 1. The dosage and frequency of nystatin administration are crucial in ensuring effective treatment of oral candidiasis, with the goal of minimizing morbidity, mortality, and improving quality of life.
Key Considerations
- The treatment duration for nystatin is typically 7-14 days, with the option to extend treatment if symptoms persist 1.
- Nystatin suspension is preferred over other topical therapies due to its ease of administration and effectiveness in treating oral candidiasis 1.
- Common side effects of nystatin include bitter taste, which may contribute to poor adherence, and mild gastrointestinal upset 1.
Alternative Treatment Options
- For mild disease, clotrimazole troches at a dosage of 10 mg 5 times daily can be used as an alternative to nystatin 1.
- For moderate to severe disease, oral fluconazole at a dosage of 100-200 mg (3 mg/kg) daily for 7-14 days is recommended 1.
Special Considerations
- Patients with fluconazole-refractory disease may require alternative treatments, such as itraconazole solution or posaconazole suspension 1.
- Chronic suppressive therapy is usually unnecessary for patients with HIV infection, but may be required in certain cases, with fluconazole at a dosage of 100 mg 3 times weekly being a recommended option 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Infants: 2 mL (200,000 units) four times daily (in infants and young children, use dropper to place one-half of dose in each side of mouth and avoid feeding for 5 to 10 minutes). NOTE: Limited clinical studies in premature and low birth weight infants indicate that 1 mL four times daily is effective. Children and Adults: 4 to 6 mL (400,000 to 600,000 units) four times daily (one-half of dose in each side of mouth). The recommended nystatin dose and frequency are:
- Infants: 2 mL (200,000 units) four times daily 2
- Premature and low birth weight infants: 1 mL four times daily 2
- Children and Adults: 4 to 6 mL (400,000 to 600,000 units) four times daily 2
From the Research
Nystatin Dose and Frequency
- The dose and frequency of nystatin can vary depending on the specific condition being treated and the population being studied.
- In a study comparing nystatin and fluconazole for the treatment of oral candidiasis in infants, nystatin oral suspension was administered four times a day for 10 days 3.
- A systematic review and meta-analysis of the efficacy of nystatin for the treatment of oral candidiasis found that nystatin pastilles at a dose of 400,000 IU resulted in a significantly higher mycological cure rate than that administered at a dose of 200,000 IU 4.
- The same review found that treatment with nystatin pastilles for 4 weeks seemed to have better clinical efficacy than treatment for 2 weeks 4.
- In terms of safety, the review found that poor taste and gastrointestinal adverse reactions are the most common adverse effects of nystatin 4.
- Another study found that nystatin had the lowest minimum inhibitory concentrations (range, 0.125-8 μg/mL; geometric mean [GM], 0.6229 μg/mL) against Candida isolates from neonates with oral thrush 5.
Comparison with Other Antifungal Agents
- A study comparing topical antifungal agents for oral candidiasis treatment found that miconazole and nystatin showed similar clinical response rates in infants, whereas miconazole presented a superior mycological cure rate 6.
- The same study found that fluconazole and amphotericin B are recommended as topical antifungal agents for adults with oral candidiasis, while miconazole is recommended for infants 6.
- A review of the treatment of oropharyngeal candidiasis in HIV-positive patients found that numerous oral and systemic therapies are used to treat oral candidiasis, including nystatin, clotrimazole, ketoconazole, fluconazole, and itraconazole 7.