What is the recommended treatment regimen for oral thrush using Nystatin (antifungal medication) swish and swallow?

Nystatin Swish and Swallow for Oral Thrush

For adults with oral thrush, use nystatin suspension 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, and continue treatment for at least 48 hours after symptoms resolve. 1, 2

Dosing and Administration

Standard Adult Regimen

• Administer 4-6 mL (400,000-600,000 units) four times daily 1, 3, 2
• Place half the dose in each side of the mouth 1
• Swish thoroughly for at least 2 minutes to ensure contact with all affected oral surfaces 2
• Swallow the medication rather than spitting it out to treat potential esophageal involvement 2

Treatment Duration

• Continue for 7-14 days 4, 3, 2
• Extend treatment for at least 48 hours after symptoms disappear and cultures confirm eradication of Candida albicans 1

Alternative Formulation

• Nystatin pastilles 200,000 units: use 1-2 pastilles four times daily for 7-14 days 4, 3, 2

Important Clinical Caveats

Limited Efficacy Compared to Fluconazole

Nystatin has significantly lower cure rates than fluconazole, particularly in immunocompromised patients. Clinical cure rates with nystatin range from only 32-54% compared to 85-100% with fluconazole 5, 6, 2. In a randomized trial of immunocompromised children, fluconazole achieved 91% clinical cure versus only 51% with nystatin 6.

When NOT to Use Nystatin as First-Line

• Moderate-to-severe oral thrush: Use oral fluconazole 100-200 mg daily instead 2
• Immunocompromised patients: Systemic azoles are more appropriate 2
• Esophageal candidiasis: Systemic therapy is required; topical nystatin is inadequate 4

Denture-Related Disease

• Thorough denture disinfection must accompany antifungal therapy for definitive cure 4, 2

Special Populations

Infants and Children

• 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
• Premature/low birth weight infants: 1 mL four times daily is effective 1

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce recurrence rates 2
• For chronic suppressive therapy if recurrences are frequent: fluconazole 100 mg three times weekly 2

Management of Treatment Failure

If Nystatin Fails

• Switch to itraconazole solution 200 mg once daily (effective in approximately two-thirds of fluconazole-refractory cases) 4, 2
• Alternative options include posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily, voriconazole 200 mg twice daily, or amphotericin B oral suspension 100 mg/mL four times daily 2
• Intravenous amphotericin B 0.3 mg/kg/day as last resort for refractory disease 4

Secondary Infections

• Take oral swabs if bacterial or candidal secondary infection is suspected 4
• Slow healing may reflect HSV reactivation 4

Adjunctive Oral Care Measures

When treating severe oral involvement (such as in Stevens-Johnson syndrome context), consider:

• White soft paraffin ointment to lips every 2 hours 4
• Mucoprotectant mouthwash three times daily 4
• Antiseptic oral rinse (1.5% hydrogen peroxide or 0.2% chlorhexidine) twice daily to reduce bacterial colonization 4
• Benzydamine hydrochloride rinse every 3 hours, particularly before eating 4