What is the recommended duration and dosage of nystatin (antifungal medication) swish and swallow for treating oral thrush?

Nystatin Swish and Swallow for Oral Thrush: Duration and Dosage

For oral thrush treatment, nystatin suspension should be administered at a dosage of 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, with treatment continuing for at least 48 hours after symptoms have resolved. 1, 2

Recommended Dosing Regimen

Adults and Children:

• Dosage: 4-6 mL (400,000-600,000 units) four times daily 2
• Administration: Swish half the dose in each side of the mouth and retain as long as possible before swallowing 2
• Duration: 7-14 days 1
• Extended treatment: Continue for at least 48 hours after perioral symptoms have disappeared and cultures demonstrate eradication of Candida albicans 2

Infants:

• Dosage: 2 mL (200,000 units) four times daily 2
• Administration: Use dropper to place one-half of dose in each side of mouth and avoid feeding for 5-10 minutes 2
• Special populations: For premature and low birth weight infants, 1 mL four times daily is effective 2

Treatment Efficacy Considerations

The Infectious Diseases Society of America (IDSA) classifies nystatin suspension as an alternative treatment for mild oral thrush with moderate-quality evidence supporting its use 1. It's important to note that:

• Nystatin is generally considered less effective than fluconazole for oral thrush treatment
• Clinical studies have shown lower cure rates with nystatin compared to azole antifungals 3, 4, 5
• For moderate to severe disease, oral fluconazole (100-200 mg daily for 7-14 days) is the recommended first-line therapy 1, 6

Important Clinical Considerations

• Treatment adherence: The four-times-daily dosing regimen may be challenging for some patients, potentially affecting treatment success
• Administration technique: Proper swish and swallow technique is crucial for efficacy - the medication should contact all areas of the oral mucosa
• Denture-related candidiasis: Disinfection of dentures is required in addition to antifungal therapy 1
• Treatment failure: If no improvement is seen after 7 days, consider:
  • Alternative diagnoses
  • Resistant Candida species
  • Need for longer treatment duration
  • Alternative antifungal agents 6

Alternative Treatment Options

For patients who fail to respond to nystatin therapy, consider:

• First-line alternatives for mild disease:

  • Clotrimazole troches (10 mg 5 times daily for 7-14 days) 1
  • Miconazole mucoadhesive buccal tablet (50 mg once daily for 7-14 days) 1

• For moderate to severe or refractory disease:

  • Fluconazole (100-200 mg daily for 7-14 days) 1, 6
  • Itraconazole solution (200 mg once daily for up to 28 days) 1, 6
  • Posaconazole suspension (400 mg twice daily for 3 days then 400 mg daily for up to 28 days) 1, 6

Monitoring and Follow-up

• Improvement typically occurs within 48-72 hours
• Complete resolution usually occurs within 7-14 days 6
• If symptoms persist beyond the recommended treatment duration, reevaluation is necessary