Nystatin Swish and Swallow for Oral Thrush
For adults and children with mild oral thrush, use nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, swishing in the mouth as long as possible before swallowing. 1
Standard Dosing by Age
Adults and Children
- Nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days 2, 1
- Place half the dose in each side of the mouth 1
- Swish thoroughly for at least 2 minutes to ensure contact with all affected areas 3
- Swallow the medication rather than spitting it out to treat potential esophageal involvement 3
Infants
- 2 mL (200,000 units) four times daily 1
- Use dropper to place half the dose in each side of mouth 1
- Avoid feeding for 5-10 minutes after administration 1
- For premature and low birth weight infants: 1 mL four times daily 1
Alternative Formulation
Duration of Treatment
- Continue for the full 7-14 days even if symptoms improve earlier 3
- Extend treatment for at least 48 hours after symptoms disappear and cultures confirm eradication of Candida albicans 1
Critical Limitations of Nystatin
Nystatin has significantly lower efficacy compared to fluconazole, particularly in moderate-to-severe disease. The evidence shows clinical cure rates of only 32-54% with nystatin versus 100% with fluconazole in infants 3, 5. In immunocompromised children, nystatin achieved only 51% clinical cure compared to 91% with fluconazole 6.
When NOT to Use Nystatin
- Moderate to severe oral thrush: Use oral fluconazole 100-200 mg daily for 7-14 days instead 2, 3
- Immunocompromised patients: Systemic therapy is more appropriate 3
- Fluconazole is superior in efficacy, tolerability, and convenience 3, 5, 6
Special Considerations
Denture-Related Candidiasis
- Disinfection of the denture is mandatory in addition to antifungal therapy 2, 4
- Without denture disinfection, reinfection is likely 4
Refractory Disease
If no clinical response within 48-72 hours, consider 4:
- Alternative diagnosis or resistant organisms
- Switch to fluconazole-refractory regimens: itraconazole solution 200 mg once daily, posaconazole suspension 400 mg twice daily, or voriconazole 200 mg twice daily 2, 3
HIV-Infected Patients
- Antiretroviral therapy is strongly recommended to reduce recurrence 2, 3
- For chronic suppression if needed: fluconazole 100 mg three times weekly 2, 3
Common Pitfalls to Avoid
- Do not use nystatin as first-line for moderate-to-severe disease—it has suboptimal efficacy 3
- Ensure patients swish thoroughly before swallowing; inadequate contact time reduces effectiveness 3
- Do not discontinue treatment early when symptoms improve; complete the full course 3, 1
- Relapse rates are higher with nystatin compared to systemic azoles 6