What is the recommended dose of nystatin (antifungal medication) mouthwash for treating oral candidiasis?

Nystatin Mouthwash Dosing for Oral Candidiasis

The recommended dose of nystatin suspension for treating oral candidiasis in adults is 4-6 mL (400,000-600,000 units) four times daily, with half the dose placed in each side of the mouth and retained as long as possible before swallowing, for 7-14 days. 1, 2

Dosing Guidelines by Age Group

Adults:

• Standard dose: 4-6 mL (400,000-600,000 units) four times daily 1
• Administration technique: Place half of dose in each side of mouth
• Duration: 7-14 days 2
• Instructions: Retain in mouth as long as possible before swallowing

Children:

• Standard dose: 4-6 mL (400,000-600,000 units) four times daily 1
• Administration technique: Same as adults

Infants:

• Standard dose: 2 mL (200,000 units) four times daily 1
• Administration technique: Use dropper to place half of dose in each side of mouth
• Special instructions: Avoid feeding for 5-10 minutes after administration

Premature/Low Birth Weight Infants:

• Reduced dose: 1 mL (100,000 units) four times daily 1

Treatment Duration and Monitoring

• Continue treatment for at least 48 hours after perioral symptoms have disappeared 1
• Ensure cultures demonstrate eradication of Candida albicans before discontinuing 1
• Schedule follow-up within 7-10 days to assess treatment response 3

Alternative Formulations

For mild disease, alternatives to suspension include:

• Nystatin pastilles (200,000 units each): 1-2 pastilles four times daily for 7-14 days 2, 4
  • Note: 400,000 IU pastilles show higher mycological cure rates than 200,000 IU pastilles 4

Treatment Considerations

For Refractory Cases

If nystatin fails to resolve the infection:

1. Consider fluconazole 100-200 mg daily for 7-14 days (for moderate to severe disease) 2, 3
2. For fluconazole-refractory cases, options include:
   • Itraconazole solution 200 mg daily for up to 28 days 2, 3
   • Posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily 2, 3

For Denture-Related Candidiasis

• Denture disinfection in addition to antifungal therapy is essential 2, 3
• Remove and disinfect dentures daily 3
• Consider leaving dentures out overnight 3

Common Pitfalls and Caveats

1. Inadequate duration: Treatment should continue for at least 48 hours after symptom resolution 1
2. Poor administration technique: Failure to retain suspension in mouth reduces effectiveness
3. Ignoring denture hygiene: For denture wearers, failure to disinfect dentures will lead to treatment failure 2, 3
4. Taste issues: Poor taste is a common adverse effect that may reduce compliance 3, 4
5. Concentration concerns: Low-concentration nystatin mouth rinses may be ineffective, as demonstrated in a study of terminally ill patients 5

For chronic recurrent cases, consider suppressive therapy with fluconazole 100 mg three times weekly rather than continuous nystatin 2, 3.