Nystatin Swish and Swallow Dosing for Oral Thrush
For oral thrush, use nystatin suspension 4-6 mL (400,000-600,000 units) four times daily, swishing thoroughly in the mouth for as long as possible before swallowing, for 7-14 days. 1, 2
Proper Administration Technique
- Swish the suspension thoroughly throughout the entire mouth for at least 2 minutes to ensure contact with all affected mucosal surfaces 3
- Swallow the medication after swishing rather than spitting it out to treat potential esophageal involvement 3, 2
- Divide the dose between both sides of the mouth (half in each cheek) for better distribution 2
- Avoid eating or drinking for 5-10 minutes after administration to maximize contact time 2
Dosing by Age Group
- Infants: 2 mL (200,000 units) four times daily using a dropper to place half the dose in each side of the mouth 2
- Premature and low birth weight infants: 1 mL four times daily is effective 2
- Children and adults: 4-6 mL (400,000-600,000 units) four times daily 1, 2
Treatment Duration and Follow-Up
- Continue treatment for the full 7-14 days even if symptoms improve earlier 1, 3
- Extend treatment for at least 48 hours after symptoms disappear and cultures confirm eradication of Candida albicans 2
Alternative Nystatin Formulation
- Nystatin pastilles (200,000 units each): 1-2 pastilles four times daily for 7-14 days as an alternative to suspension 1
- Pastilles are better tolerated than suspensions at higher doses and may improve compliance 4, 5
Critical Caveat: When NOT to Use Nystatin
For moderate to severe oral thrush, nystatin is NOT first-line therapy—use oral fluconazole 100-200 mg daily for 7-14 days instead 1, 3. The evidence is compelling:
- Nystatin has significantly lower clinical cure rates (32-54%) compared to fluconazole (91-100%) in controlled trials 6, 7
- Nystatin has suboptimal tolerability and requires four-times-daily dosing versus once-daily fluconazole 3, 7
- Reserve nystatin for mild disease only; immunocompromised patients and those with moderate-to-severe disease require systemic azole therapy 1, 3
Special Considerations
- For denture-related candidiasis, disinfect dentures concurrently with antifungal therapy to prevent reinfection 1, 5
- For HIV-infected patients with recurrent infections, initiate antiretroviral therapy to reduce recurrence rates 1, 3
- For chronic suppressive therapy in recurrent cases, fluconazole 100 mg three times weekly is more effective than continued nystatin 1, 3