Nystatin Swish and Swallow Dosing for Thrush
For adults with oral thrush, the recommended nystatin swish and swallow dosing is 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, with instructions to retain the suspension in the mouth as long as possible before swallowing. 1, 2
Dosing Recommendations by Patient Population
Adults:
- 4-6 mL (400,000-600,000 units) of nystatin suspension four times daily for 7-14 days 1, 3
- Alternative: 1-2 nystatin pastilles (200,000 units each) four times daily for 7-14 days 3, 2
Children:
Infants:
- 2 mL (200,000 units) four times daily 1
- For premature and low birth weight infants: 1 mL four times daily 1
Proper Administration Technique
- Instruct patients to swish the suspension thoroughly in the mouth for as long as possible (at least 2 minutes) before swallowing 2
- For infants and young children, use the dropper to place one-half of the dose in each side of the mouth 1
- Avoid feeding infants for 5-10 minutes after administration 1
- Continue treatment for at least 48 hours after symptoms have disappeared and cultures demonstrate eradication of Candida albicans 1
- For denture-related candidiasis, disinfection of the denture must accompany antifungal therapy 3, 2
Treatment Algorithm Based on Disease Severity
Mild Oral Thrush:
- First-line: Nystatin suspension (100,000 units/mL) 4-6 mL four times daily for 7-14 days 3, 2
- Alternative: Clotrimazole troches, 10 mg 5 times daily for 7-14 days 3
Moderate to Severe Oral Thrush:
- First-line: Oral fluconazole 100-200 mg daily for 7-14 days 3, 2
- Nystatin is less effective than fluconazole for moderate to severe cases 4, 5
Special Considerations
- Clinical efficacy of nystatin may be lower compared to azole antifungals, with studies showing clinical cure rates of 32-54% for nystatin versus 91-100% for fluconazole 4, 5
- For immunocompromised patients with recurrent infections, systemic therapy with fluconazole may be more appropriate than topical nystatin 2
- For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 3, 2
- For chronic suppressive therapy in patients with recurrent infection, fluconazole 100 mg three times weekly is recommended rather than ongoing nystatin 3, 2
Common Pitfalls and Caveats
- Failure to continue treatment for the full recommended duration (7-14 days) even if symptoms improve sooner 2
- Inadequate contact time between medication and oral mucosa (should swish for at least 2 minutes) 2
- Not addressing underlying factors such as denture hygiene in denture-related candidiasis 3, 2
- Using nystatin instead of systemic therapy for moderate to severe cases, which may lead to treatment failure 3, 2
- Not considering alternative therapies when nystatin fails, as studies show higher relapse rates with nystatin compared to azole antifungals 6, 7