What is the recommended dosing for nystatin (antifungal medication) in the treatment of oral thrush?

From the Guidelines

Nystatin suspension is recommended at a dose of 4–6 mL (100,000 U/mL) 4 times daily for 7–14 days for the treatment of oral thrush. This dosing is based on strong recommendation and moderate-quality evidence from the 2016 update by the Infectious Diseases Society of America 1.

Key Considerations

• The treatment duration is typically 7-14 days, but it may need to be extended in severe or recurrent cases.
• Nystatin pastilles can also be used as an alternative, with a dose of 1–2 pastilles (200,000 U each) 4 times daily for 7–14 days 1.
• It is essential to use nystatin after meals and any oral hygiene to maximize contact time with the infected tissues.
• Patients should avoid eating or drinking for 30 minutes after administration to ensure the medication has sufficient time to work.
• If using dentures, they should be removed during nystatin application and disinfected separately to prevent reinfection.

Additional Options

• For mild disease, clotrimazole troches or miconazole mucoadhesive buccal tablets can be used as alternatives to nystatin 1.
• For moderate to severe disease, oral fluconazole is recommended, and for fluconazole-refractory disease, itraconazole solution or posaconazole suspension can be used 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 dosing for nystatin in the treatment of oral thrush is:

• Infants: 2 mL (200,000 units) four times daily
• Children and Adults: 4 to 6 mL (400,000 to 600,000 units) four times daily Treatment should continue for at least 48 hours after perioral symptoms have disappeared and cultures demonstrate eradication of Candida albicans 2

From the Research

Nystatin Dosing for Oral Thrush

• The recommended dosing for nystatin in the treatment of oral thrush is not consistently defined across studies, but several studies provide insight into its usage:
  • A study from 1995 3 used nystatin at a dose of 400,000 units four times daily for 14 days in immunocompromised children.
  • Another study from 2002 4 used nystatin oral suspension four times a day for 10 days in infants, but the exact dosage per unit is not specified.
  • A study from 1997 5 compared miconazole gel with nystatin suspension, with the nystatin dosage being 100,000 IU four times daily after meals.
  • A study from 1989 6 evaluated the effectiveness of a nystatin pastille at two different dosages: 200,000 units and 400,000 units.

Efficacy of Nystatin

• The efficacy of nystatin in treating oral thrush varies across studies:
  • The 1995 study 3 found that nystatin was less effective than fluconazole in treating oral thrush in immunocompromised children, with a clinical cure rate of 51%.
  • The 2002 study 4 found that nystatin had a clinical cure rate of 32% in infants, compared to 100% for fluconazole.
  • The 1997 study 5 found that nystatin had a lower clinical cure rate than miconazole gel, with 21.2% of subjects achieving clinical cure by Day 5 of treatment.
  • The 1989 study 6 found that both dosages of nystatin pastille were effective in reducing or eliminating Candida organisms during active therapy.

Comparison with Other Treatments

• Nystatin is often compared to other antifungal medications in the treatment of oral thrush:
  • Fluconazole is shown to be more effective than nystatin in several studies 3, 4, 7.
  • Miconazole gel is also shown to be more effective than nystatin in one study 5.