Nystatin Swish and Swallow for Oral Thrush
For mild oral thrush, nystatin suspension should be dosed at 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, with the medication swished in the mouth as long as possible before swallowing, though fluconazole is preferred for moderate-to-severe disease due to superior efficacy. 1, 2
Dosing and Administration
Standard Adult Dosing
- Nystatin suspension: 4-6 mL (400,000-600,000 units) four times daily 3, 1, 2
- Alternative: Nystatin pastilles 1-2 tablets (200,000 units each) four times daily 1
- Treatment duration: 7-14 days minimum 3, 1, 2
Proper Swish and Swallow Technique
- Swish the suspension thoroughly throughout the mouth for as long as possible (at least 2 minutes) to ensure contact with all affected areas 1
- Swallow the medication after swishing rather than spitting it out to treat potential esophageal involvement 1
- Place one-half of the dose in each side of the mouth 2
- Continue treatment for at least 48 hours after symptoms resolve and cultures confirm eradication of Candida 2
Treatment Algorithm by Disease Severity
Mild Oral Thrush
- First-line options include clotrimazole troches (10 mg 5 times daily) or nystatin suspension as described above 4
- Miconazole mucoadhesive buccal tablet (50 mg once daily) is an alternative 4
Moderate-to-Severe Oral Thrush
- Oral fluconazole 100-200 mg daily for 7-14 days is first-line therapy and superior to nystatin 3, 4, 1
- Nystatin is relegated to mild disease due to lower efficacy compared to systemic azoles 3
Important Clinical Caveats
Limitations of Nystatin
- Topical agents like nystatin have suboptimal tolerability (bitter taste, gastrointestinal side effects, frequent dosing) and lower efficacy compared to fluconazole 3
- Research demonstrates nystatin clinical cure rates of only 32-54% compared to 100% with fluconazole in infants 5, 6
- Nystatin should not be first-line for moderate-to-severe disease or immunocompromised patients 3, 1
Special Populations and Considerations
- For denture-related candidiasis, denture disinfection must accompany antifungal therapy, with dentures removed at night and cleaned thoroughly 4, 1
- For HIV-infected patients, antiretroviral therapy is strongly recommended to reduce recurrent infections, and systemic therapy may be more appropriate 4, 1
- For recurrent oral thrush, fluconazole 100 mg three times weekly is recommended for chronic suppressive therapy 4, 1
Refractory Disease
If symptoms persist despite nystatin treatment:
- Itraconazole solution 200 mg once daily 3, 4
- Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily 3, 4
- Voriconazole 200 mg twice daily 3, 4
- Amphotericin B oral suspension 100 mg/mL four times daily 3, 4