What is the treatment for oral thrush using nystatin?

Nystatin Treatment for Oral Thrush

For oral thrush, nystatin suspension at a dose of 100,000 U/mL, 4-6 mL four times daily for 7-14 days, or nystatin pastilles (200,000 U each), 1-2 pastilles four times daily for 7-14 days are effective treatment options. 1, 2

Dosage and Administration

• Nystatin suspension:

  • Dosage: 100,000 U/mL, 4-6 mL four times daily
  • Duration: 7-14 days
  • Administration: Swish in mouth for as long as possible before swallowing

• Nystatin pastilles:

  • Dosage: 200,000 U each, 1-2 pastilles four times daily
  • Duration: 7-14 days
  • Administration: Allow to dissolve slowly in the mouth

Efficacy Considerations

• Nystatin pastilles may achieve a higher mycological cure rate compared to suspension alone 3
• Combination of pastilles and suspension for 2 weeks may provide better outcomes than either formulation alone 3
• Pastilles at a dose of 400,000 IU show significantly higher mycological cure rates than 200,000 IU 3
• Treatment for 4 weeks may have better clinical efficacy than the standard 2-week regimen for persistent cases 3

Treatment Alternatives

For moderate to severe cases or when nystatin is ineffective:

• Fluconazole 100-200 mg daily for 7-14 days is more effective than topical therapy in some studies 1, 2
• Clotrimazole troches (10 mg five times daily for 7-14 days) are an alternative topical option 2, 1
• Itraconazole solution (200 mg/day) for refractory cases 2

Special Considerations

• Denture-related thrush: Requires thorough disinfection of dentures in addition to antifungal therapy 2, 1
• Immunocompromised patients: May require longer treatment duration and closer follow-up 1
• Assessment: Clinical response should be evaluated within 3-5 days of treatment initiation 1

Common Pitfalls and Caveats

1. Poor taste: Nystatin has a bitter taste that may affect compliance, especially in children
2. Gastrointestinal side effects: May cause nausea or digestive discomfort in some patients 3
3. Sugar content: Some commercial nystatin formulations contain sugar, which may contribute to dental caries; sugar-free alternatives should be considered when available 4
4. Incomplete treatment: Patients should be advised to complete the full course of treatment even if symptoms resolve quickly
5. Prevention measures: Patients should be educated about proper oral hygiene, denture care, and rinsing after using inhaled corticosteroids 1

Treatment Algorithm

1. For initial, mild-moderate oral thrush:

   • Start with nystatin suspension 100,000 U/mL, 4-6 mL four times daily for 7-14 days
   • OR nystatin pastilles 200,000 U, 1-2 pastilles four times daily for 7-14 days

2. If inadequate response after 3-5 days:

   • Consider combination of nystatin suspension and pastilles
   • OR switch to fluconazole 100 mg daily for 7-14 days

3. For refractory cases:

   • Extend nystatin treatment to 4 weeks
   • OR switch to itraconazole solution 200 mg daily
   • Consider amphotericin B oral suspension for fluconazole-refractory disease