What is the treatment regimen for fungal infections using Nystatin?

Nystatin Treatment Regimens for Fungal Infections

For mild oropharyngeal candidiasis, use nystatin suspension 100,000 U/mL at 4-6 mL four times daily OR nystatin pastilles 200,000 U, taking 1-2 pastilles 4-5 times daily for 7-14 days, though oral fluconazole is generally more effective for moderate-to-severe disease. 1

Oropharyngeal Candidiasis

Mild Disease

• Nystatin suspension: 100,000 U/mL, dose of 4-6 mL four times daily for 7-14 days 1
• Nystatin pastilles: 200,000 U each, 1-2 pastilles 4-5 times daily for 7-14 days 1
• These are considered alternatives to clotrimazole troches, with strong recommendation but moderate-quality evidence 1

Important Considerations for Oropharyngeal Use

• Combination therapy may be superior: Using nystatin pastilles and suspension together for 2 weeks appears to achieve higher clinical and mycological cure rates compared to suspension alone 2
• Pastilles alone are more effective than suspension alone for mycological cure 2
• Higher doses work better: Nystatin pastilles at 400,000 IU show significantly higher mycological cure rates than 200,000 IU 2
• Extended duration improves outcomes: Treatment for 4 weeks appears more effective than 2 weeks 2

When Nystatin is NOT Recommended

• Moderate-to-severe oropharyngeal candidiasis: Oral fluconazole 100-200 mg daily for 7-14 days is preferred 1
• Esophageal candidiasis: Topical therapy including nystatin is ineffective; systemic azoles are required 1
• Immunocompromised patients with severe disease: Nystatin cannot be recommended for prophylaxis or treatment in severely immunodepressed patients based on evidence showing no benefit over placebo 3

Cutaneous Candidiasis

Skin Infections and Intertrigo

• Topical nystatin is effective for nonhematogenous primary skin infections, particularly intertrigo in skin folds 1
• Must keep infected area dry as an essential adjunct to treatment 1
• Equally effective as other topical azoles (clotrimazole, miconazole) for this indication 1

Paronychia

• Nystatin may be used but drainage is the most important intervention 1

Vulvovaginal Candidiasis

C. glabrata Infections (Azole-Resistant)

• Nystatin intravaginal suppositories: 100,000 units daily for 14 days 1
• This is an alternative when C. glabrata is unresponsive to oral azoles 1
• Strong recommendation with low-quality evidence 1

Neonatal Prophylaxis

Prevention in High-Risk Neonates

• Oral nystatin: 100,000 units three times daily for 6 weeks 1
• Indicated for neonates with birth weights <1500 g in situations where fluconazole availability or resistance precludes its use 1
• This is a weak recommendation with moderate-quality evidence 1
• Fluconazole prophylaxis is preferred when available for neonates <1000 g in nurseries with high invasive candidiasis rates (>10%) 1

Critical Limitations and Pitfalls

Where Nystatin Fails

• Not absorbed systemically: Cannot treat invasive or systemic fungal infections 4
• Inferior to fluconazole: Multiple studies show nystatin suspension is not superior to fluconazole in infants, children, or HIV/AIDS patients with oral candidiasis 2
• Poor efficacy in immunocompromised hosts: Meta-analysis shows nystatin has no significant benefit over placebo for fungal colonization in severely immunodepressed patients 3
• Onychomycosis: Topical agents including nystatin are usually ineffective 1

Formulation Concerns

• Sugar content: Some commercial nystatin formulations contain sugar, which can promote dental caries and should be avoided when possible 5
• Taste issues: Poor taste is the most common adverse effect, potentially affecting compliance 2
• Gastrointestinal effects: Most common adverse reactions beyond taste 2

Resistance Considerations

• Variable post-antifungal effect: C. albicans shows the shortest post-antifungal effect (6.85 hours) compared to non-albicans species, which may explain chronic recurrence despite adequate treatment 6
• Non-albicans species: C. parapsilosis shows longest post-antifungal effect (15.17 hours), suggesting species-specific dosing intervals may be important 6

FDA-Approved Indication

Nystatin oral suspension is indicated specifically for treatment of candidiasis in the oral cavity only 4. Any use beyond this represents off-label prescribing, though supported by guidelines for certain cutaneous and vaginal applications.