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

Nystatin Dosing for Oral Thrush

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 the medication retained in the mouth as long as possible before swallowing. 1, 2

Dosing Recommendations by Age Group

• Adults and Children:

  • Nystatin suspension: 4-6 mL (400,000-600,000 units) four times daily for 7-14 days 3, 1, 2
  • Alternative: 1-2 nystatin pastilles (200,000 units each) four times daily for 7-14 days 3, 1

• Infants:

  • Nystatin suspension: 2 mL (200,000 units) four times daily 2
  • For premature and low birth weight infants: 1 mL four times daily 2

Administration Technique

• Instruct patients to swish the suspension thoroughly in the mouth, ensuring contact with all affected areas for at least 2 minutes 1
• 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
• After swishing, the medication should be swallowed rather than spit out to treat potential esophageal involvement 1
• Continue treatment for at least 48 hours after symptoms have disappeared and cultures demonstrate eradication of Candida albicans 2

Treatment Algorithm Based on Disease Severity

• For mild oral thrush:

  • First-line: Nystatin suspension 4-6 mL four times daily for 7-14 days 3, 1

• For moderate to severe oral thrush:

  • First-line: Oral fluconazole 100-200 mg daily for 7-14 days (more effective than topical nystatin) 3, 1

• For fluconazole-refractory disease:

  • Itraconazole solution 200 mg once daily OR posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily, for up to 28 days 3

Special Considerations

• For denture-related candidiasis, disinfection of the denture must accompany antifungal therapy 3, 1
• For HIV-infected patients with recurrent infections, antiretroviral therapy is strongly recommended to reduce recurrence 3, 1
• For chronic suppressive therapy in patients with recurrent infection, fluconazole 100 mg three times weekly is recommended 3, 1

Clinical Efficacy Considerations

• Several studies have shown that systemic antifungals (fluconazole, miconazole) have higher clinical cure rates compared to nystatin for oral thrush, particularly in immunocompromised patients 4, 5, 6
• In immunocompetent infants, miconazole gel demonstrated significantly higher cure rates by day 5 (84.7%) compared to nystatin suspension (21.2%) 6
• Despite these comparative efficacy findings, nystatin remains a first-line option for mild cases of oral thrush due to its safety profile and topical mechanism of action 3, 1

Treatment Duration

• Continue nystatin therapy for the full 7-14 days even if symptoms improve sooner 1
• Treatment should continue for at least 48 hours after perioral symptoms have disappeared 2