What is the recommended dose of nystatin (antifungal medication) for oral candidiasis?

Nystatin Dosing for Oral Candidiasis

For mild oral candidiasis in adults and children, use nystatin suspension (100,000 units/mL) at a dose of 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, swishing the medication in the mouth as long as possible before swallowing. 1, 2

Dosing Regimens

Standard Suspension Dosing

• Adults and children: 4-6 mL (400,000-600,000 units) four times daily for 7-14 days 1, 2
• 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/low birth weight infants: 1 mL four times daily has been shown effective in limited studies 2

Alternative Pastille Dosing

• Adults and children: 1-2 nystatin pastilles (200,000 units each) four times daily for 7-14 days 1

Administration Technique

Critical administration points that affect treatment success:

• Swish the suspension thoroughly throughout the mouth for as long as possible (at least 2 minutes) to ensure contact with all affected areas 3
• Swallow the medication after swishing rather than spitting it out to treat potential esophageal involvement 3
• In infants, avoid feeding for 5-10 minutes after administration 2
• Continue treatment for at least 48 hours after symptoms resolve and cultures confirm eradication of Candida 2

When Nystatin is NOT Appropriate

For moderate to severe oral candidiasis, oral fluconazole 100-200 mg daily for 7-14 days is superior to nystatin and should be used instead. 1, 3

Key Limitations of Nystatin

• Clinical cure rates with nystatin are only 32-54% compared to 87-100% with fluconazole 4, 5
• Nystatin has suboptimal tolerability and higher relapse rates 3, 4
• Fluconazole provides longer disease-free intervals before relapse (18% vs 44% relapse rate at day 28) 4

Disease Severity Algorithm

Mild disease (limited oral involvement, minimal symptoms):

• First-line: Nystatin suspension 4-6 mL four times daily OR clotrimazole troches 10 mg five times daily for 7-14 days 1

Moderate to severe disease (extensive involvement, significant symptoms, immunocompromised):

• First-line: Oral fluconazole 100-200 mg daily for 7-14 days 1
• Nystatin should NOT be used as first-line therapy 3

Special Populations and Considerations

Denture-Related Candidiasis

• Denture disinfection MUST accompany antifungal therapy for treatment success 1, 3
• Nystatin alone without denture disinfection has poor efficacy 6

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce recurrent infections 1
• For recurrent infections requiring suppression, use fluconazole 100 mg three times weekly rather than chronic nystatin 1

Refractory Disease

If nystatin fails after 7-14 days, escalate to:

• Itraconazole solution 200 mg once daily 1
• Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily 1
• Voriconazole 200 mg twice daily 1

Common Pitfalls to Avoid

• Do not use nystatin for moderate-severe disease or immunocompromised patients - fluconazole is significantly more effective 3, 4, 5
• Do not stop treatment when symptoms improve - continue for full 7-14 days and at least 48 hours after symptom resolution 2
• Do not neglect proper swishing technique - inadequate contact time reduces efficacy 3
• Do not forget denture disinfection - treating the infection without addressing denture contamination leads to treatment failure 1, 6