What is the recommended dosage and treatment approach for Nystatin (antifungal medication) swish and swallow for oral thrush?

Nystatin Swish and Swallow for Oral Thrush

For mild oral thrush, use nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, instructing patients to swish thoroughly before swallowing; however, for moderate to severe disease, oral fluconazole 100-200 mg daily is superior and should be used instead. 1

Dosing Protocol

Standard Adult and Pediatric Dosing

• Nystatin suspension (100,000 units/mL): 4-6 mL four times daily for 7-14 days 1, 2
• Alternative formulation: 1-2 nystatin pastilles (200,000 units each) four times daily for 7-14 days 1
• For infants: 2 mL (200,000 units) four times daily, using a dropper to place half the dose in each side of the mouth 2
• For premature and low birth weight infants: 1 mL four times daily is effective 2

Administration Technique

• Swish the suspension thoroughly in the mouth for at least 2 minutes, ensuring contact with all affected areas 3
• Swallow the medication after swishing rather than spitting it out to treat potential esophageal involvement 3
• Avoid feeding for 5-10 minutes after administration in infants and young children 2
• Continue treatment for at least 48 hours after symptoms disappear and cultures confirm eradication 2

Treatment Algorithm by Disease Severity

Mild Disease (First-Line Options)

• Clotrimazole troches 10 mg five times daily for 7-14 days (preferred over nystatin) 1
• Miconazole mucoadhesive buccal 50-mg tablet applied once daily for 7-14 days 1
• Nystatin suspension or pastilles as detailed above (alternative option) 1

Moderate to Severe Disease

• Oral fluconazole 100-200 mg daily for 7-14 days is the recommended treatment 1
• This represents a strong recommendation with high-quality evidence and should be prioritized over topical agents 1

Fluconazole-Refractory Disease

• Itraconazole solution 200 mg once daily for up to 28 days 1
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1
• Voriconazole 200 mg twice daily 1
• Intravenous echinocandin or amphotericin B deoxycholate for severe refractory cases 1

Special Populations and Considerations

Denture-Related Candidiasis

• Denture disinfection must accompany antifungal therapy for successful treatment 1, 3
• Use standard nystatin or fluconazole dosing as above 1

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce recurrent infections 1, 3
• For chronic suppression if needed: fluconazole 100 mg three times weekly 1, 3
• Chronic suppressive therapy is usually unnecessary but may be required for recurrent infections 1

Immunocompromised Patients

• Systemic therapy with fluconazole may be more appropriate than topical nystatin for recurrent infections 3
• Consider higher intensity or longer duration therapy based on immune status 1

Evidence Quality and Clinical Pearls

Nystatin has moderate-quality evidence supporting its use for mild oral thrush 1, while fluconazole has high-quality evidence for moderate to severe disease 1. Research demonstrates that fluconazole achieves 100% clinical cure rates compared to only 32% with nystatin in some pediatric studies 4, though a 2022 meta-analysis showed nystatin remains effective when used appropriately 5.

Common Pitfalls to Avoid

• Do not use nystatin for moderate to severe disease when fluconazole is available and appropriate 1
• Do not discontinue treatment early even if symptoms improve; complete the full 7-14 day course 2
• Do not neglect denture disinfection in denture wearers, as this leads to treatment failure 1
• Do not use nystatin for esophageal candidiasis; systemic therapy is always required 1

Duration of Therapy

• Standard treatment: 7-14 days for oral thrush 1, 2
• Continue for at least 48 hours after symptom resolution and negative cultures 2
• Esophageal involvement requires 14-21 days of systemic therapy 1