What is the oral nystatin dosing for candidiasis?

From the Guidelines

The recommended oral nystatin dosage for candidiasis is 100,000 U/mL, with a dosage of 4–6 mL 4 times daily, or 1–2 nystatin pastilles (200,000 U each) administered 4 times daily for 7–14 days. To use:

• Shake the liquid suspension well before each dose
• Use the provided dropper or measuring device for accurate dosing
• Swish the medication in the mouth for several minutes before swallowing
• Take with food to reduce stomach upset Nystatin works by binding to ergosterol in the fungal cell membrane, creating pores that lead to cell death, as recommended by the Infectious Diseases Society of America in their 2016 clinical practice guideline update 1. This guideline provides strong recommendations with moderate-quality evidence for the use of nystatin suspension or pastilles for mild disease. Side effects are usually mild but may include nausea, vomiting, or diarrhea, and if symptoms persist after treatment, consulting a healthcare provider for a different antifungal may be necessary. The 2016 guideline update 1 is preferred over the 2009 update 1 due to its more recent publication and high-quality evidence. Key points to consider when treating candidiasis include:
• The use of antifungal therapy, such as nystatin, for mild disease
• The recommendation for oral fluconazole for moderate to severe disease 1
• The importance of disinfecting dentures in addition to antifungal therapy for denture-related candidiasis 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 oral nystatin dosing for candidiasis is:

• Infants: 2 mL (200,000 units) four times daily
• Premature and low birth weight infants: 1 mL four times daily
• Children and Adults: 4 to 6 mL (400,000 to 600,000 units) four times daily 2

From the Research

Oral Nystatin Dosing for Candidiasis

• The optimal dosing of oral nystatin for candidiasis is not universally established, but several studies provide guidance on effective treatment protocols 3, 4.
• Nystatin pastilles at a dose of 400,000 IU have been shown to result in a significantly higher mycological cure rate than those administered at a dose of 200,000 IU 3.
• Treatment with nystatin pastilles for 4 weeks may have better clinical efficacy than treatment for 2 weeks 3.
• The use of nystatin suspension and pastilles in combination for 2 weeks may achieve a higher clinical and mycological cure rate compared to using nystatin suspensions alone 3.
• A study comparing nystatin oral suspensions to fluconazole for the treatment of oral candidiasis in infants found that fluconazole was superior to nystatin suspension, with clinical cures of 100% for fluconazole and 32% for nystatin 5.
• Another study found that nystatin pastilles can be expected to be more effective at killing Candida albicans than the suspension due to their persistent effects, with antifungal activity detectable for at least 5 hours after use of the nystatin pastille 4.