What is the dosage and treatment plan for Nystatin (antifungal medication) in treating fungal infections?

Nystatin Dosing and Treatment for Fungal Infections

For mild oropharyngeal candidiasis, nystatin suspension (100,000 U/mL) 4–6 mL four times daily OR nystatin pastilles (200,000 U each) 1–2 pastilles four times daily for 7–14 days is recommended as an alternative to topical azoles, though fluconazole remains superior for moderate-to-severe disease. 1

Oropharyngeal Candidiasis

Mild Disease

• Nystatin suspension: 4–6 mL (400,000–600,000 units) four times daily for 7–14 days 1, 2
• Nystatin pastilles: 1–2 pastilles (200,000 units each) 4–5 times daily for 7–14 days 1
• The preparation should be retained in the mouth as long as possible before swallowing 2
• Continue treatment for at least 48 hours after symptoms disappear and cultures confirm eradication 2

Pediatric Dosing

• Infants: 2 mL (200,000 units) four times daily using dropper to place half the dose in each side of mouth; avoid feeding for 5–10 minutes 2
• Premature/low birth weight infants: 1 mL four times daily is effective 2
• Children: 4–6 mL (400,000–600,000 units) four times daily 2

Important Caveats

• Nystatin is NOT recommended for moderate-to-severe oropharyngeal candidiasis—oral fluconazole 100–200 mg daily is superior 1
• Nystatin is positioned as an alternative when azoles cannot be used 1
• For fluconazole-refractory disease, nystatin is NOT recommended; use itraconazole solution or posaconazole instead 1

Vulvovaginal Candidiasis

C. glabrata Infection (Azole-Refractory)

• Nystatin intravaginal suppositories: 100,000 units daily for 14 days 1
• This is an alternative when topical boric acid (600 mg daily for 14 days) is not available 1
• Another option is topical 17% flucytosine cream alone or combined with 3% amphotericin B cream for 14 days 1

Uncomplicated Vulvovaginal Candidiasis

• Topical antifungal agents are preferred over nystatin 1
• Single-dose oral fluconazole 150 mg is the recommended systemic option 1

Esophageal Candidiasis

Nystatin is NOT effective for esophageal candidiasis—systemic therapy with fluconazole 200–400 mg daily for 14–21 days is required 1

Cutaneous Candidiasis

• Topical nystatin is effective for candidal skin infections (intertrigo) in skin folds 1
• Keep the infected area dry as an essential adjunct to treatment 1
• For paronychia, drainage is the most important intervention 1

Denture-Related Candidiasis

• Nystatin can be used for denture stomatitis, but disinfection of the denture is mandatory in addition to antifungal therapy 1
• Meta-analysis shows nystatin pastille is significantly superior to placebo for denture stomatitis 3

Efficacy Considerations

Comparative Effectiveness

• Nystatin suspension is NOT superior to fluconazole for oral candidiasis in infants, children, or HIV/AIDS patients 3
• Combining nystatin suspension and pastilles for 2 weeks may achieve higher cure rates than suspension alone 3
• Higher doses are more effective: Nystatin pastilles at 400,000 IU result in significantly higher mycological cure rates than 200,000 IU 3
• Longer duration improves outcomes: Treatment for 4 weeks appears more effective than 2 weeks 3

Prophylaxis

• Nystatin is LESS effective than fluconazole for preventing candida infections in leukemia patients undergoing chemotherapy 4
• Prophylaxis success: fluconazole 68% vs nystatin 47% (P = 0.03) 4
• In pediatric cancer patients, fluconazole and nystatin showed similar efficacy, but fluconazole had better yeast eradication 5

Common Pitfalls

• Do not use nystatin for systemic or invasive candidiasis—it is not absorbed systemically and is ineffective 1
• Do not use nystatin for esophageal candidiasis—topical therapy cannot reach the esophagus adequately 1
• Poor taste and gastrointestinal adverse reactions are the most common side effects 3
• Oropharyngeal fungal cultures are of little benefit since many individuals have asymptomatic colonization 1
• Repeated courses or suppressive therapy with any agent increases risk of azole-refractory infections 1