What is the recommended treatment and dosage for oral thrush using nystatin (antifungal medication)?

Nystatin Treatment for Oral Thrush

For the treatment of oral thrush (oropharyngeal candidiasis), nystatin suspension should be administered at a dosage of 4-6 mL (400,000-600,000 units) four times daily for 7-14 days. 1, 2

Dosing Recommendations by Age Group

• Adults and Children: 4-6 mL (400,000-600,000 units) of nystatin suspension (100,000 units/mL) four times daily for 7-14 days 1, 2
• Infants: 2 mL (200,000 units) four times daily 2
• Premature and Low Birth Weight Infants: 1 mL four times daily 2
• Alternative for Adults and Children: 1-2 nystatin pastilles (200,000 units each) four times daily for 7-14 days 1

Administration Guidelines

• The suspension should be retained in the mouth as long as possible before swallowing 2
• For infants and young children, use a dropper to place one-half of the dose in each side of the mouth 2
• Avoid feeding infants for 5-10 minutes after administration 2
• Continue treatment for at least 48 hours after perioral symptoms have disappeared and cultures demonstrate eradication of Candida albicans 2

Treatment Algorithm

For Mild Oral Thrush:

1. First-line: Nystatin suspension (100,000 units/mL) 4-6 mL four times daily for 7-14 days 1
2. Alternative: Nystatin pastilles (200,000 units each) 1-2 pastilles four times daily for 7-14 days 1
3. Other options: Clotrimazole troches (10 mg) five times daily for 7-14 days 1

For Moderate to Severe Oral Thrush:

1. First-line: Oral fluconazole 100-200 mg daily for 7-14 days 1
2. For fluconazole-refractory disease: Itraconazole solution 200 mg daily or posaconazole suspension 1

For Denture-Related Candidiasis:

• Disinfection of the denture in addition to antifungal therapy is essential 1

Efficacy Considerations

• Nystatin pastilles appear to have higher mycological cure rates than suspension alone 3
• Combination of nystatin suspension and pastilles for 2 weeks may achieve higher clinical and mycological cure rates 3
• Nystatin pastilles at 400,000 IU have shown significantly higher mycological cure rates than 200,000 IU 3
• Treatment duration of 4 weeks may provide better clinical efficacy than 2 weeks for persistent cases 3
• Fluconazole has demonstrated superior efficacy compared to nystatin suspension in some studies, particularly in infants 4, 3

Common Side Effects and Precautions

• Poor taste is the most common adverse effect 3
• Gastrointestinal reactions may occur 3
• For HIV-infected patients with recurrent infections, antiretroviral therapy is strongly recommended to reduce recurrence 1

Special Considerations

• For chronic suppressive therapy (usually unnecessary), fluconazole 100 mg three times weekly is recommended for recurrent infections 1
• For immunocompromised patients with recurrent infections, systemic therapy may be more appropriate 1
• Clinical studies have shown that ketoconazole and miconazole gel may be more effective than nystatin suspension in some patient populations 5, 6