Nystatin Prophylaxis for Fungal Peritonitis in Peritoneal Dialysis Patients on Antibiotics
Oral nystatin 500,000 units four times daily should be given throughout the entire course of antibiotic therapy and continued for 5 days after antibiotics are completed to prevent antibiotic-related fungal peritonitis in peritoneal dialysis patients.
Dosing Regimen
The recommended nystatin prophylaxis protocol is 1, 2, 3:
- Dose: 500,000 units orally four times daily
- Timing: Start at the initiation of antibiotic therapy
- Duration: Continue throughout the entire antibiotic course and extend for 5 days after antibiotics are discontinued
- Formulation: Nystatin tablets are typically used 1, 3
Evidence Supporting This Approach
Efficacy Data
Nystatin prophylaxis significantly reduces antibiotic-related fungal peritonitis (AR-FP), which is the primary target of this intervention:
- A large observational study of 801 patients (22,600 patient-months) demonstrated a significant decrease in AR-FP incidence when nystatin prophylaxis was implemented, even after adjusting for overall peritonitis rates 1
- Kaplan-Meier analysis showed significantly better AR-FP-free survival in patients receiving nystatin prophylaxis 1
- A 6-year experience showed dramatic reduction in fungal peritonitis from 10.5% to 3.1% of all peritonitis episodes after introducing nystatin prophylaxis (P < 0.05) 2
- A prospective randomized controlled trial demonstrated higher CP-free survival at 2 years (0.974 vs 0.915; P < 0.05) with nystatin prophylaxis 3
Important Nuances in the Evidence
The evidence shows some variability in outcomes, which requires careful interpretation:
- Programs with already low baseline fungal peritonitis rates may see less dramatic benefits, though the trend toward reduction in AR-FP remains consistent 1
- One negative study from 1998 showed no benefit, but this may reflect differences in baseline fungal peritonitis epidemiology or patient populations 4
- The benefit appears most pronounced specifically for antibiotic-related fungal peritonitis rather than de novo fungal peritonitis 1, 3
Alternative: Fluconazole Prophylaxis
For programs preferring systemic prophylaxis, fluconazole 50 mg daily can be used as an alternative 5:
- Dose: 50 mg orally once daily
- Duration: Throughout antibiotic therapy
- A 6-year retrospective study showed zero episodes of AR-FP with this regimen 5
- This is a lower dose than typically used in other settings and appears effective specifically for peritoneal dialysis patients
Safety Profile
Nystatin prophylaxis has an excellent safety profile with no significant side effects reported in multiple studies 1, 2, 3, 4. This is expected given that nystatin is a non-absorbable antifungal agent that acts locally in the gastrointestinal tract 2.
Clinical Context and Pitfalls
When to Implement
Nystatin prophylaxis should be given whenever antibiotics are prescribed for any indication in peritoneal dialysis patients, not just for bacterial peritonitis 2. This includes:
- Treatment of bacterial peritonitis
- Treatment of exit-site or tunnel infections
- Antibiotics for any systemic infection
Common Pitfall to Avoid
The most critical error is failing to give prophylaxis at all—in one study, all four patients who developed fungal peritonitis during the prophylaxis era had not actually received nystatin 2. Ensure systematic protocols are in place so prophylaxis is automatically co-prescribed with antibiotics.
Program-Specific Considerations
Programs with higher baseline fungal peritonitis rates (>5% of all peritonitis episodes) will see more dramatic benefits from implementing nystatin prophylaxis 2. However, even programs with modest baseline rates show significant reductions in AR-FP specifically 1.
Guideline Context
While the IDSA Candidiasis Guidelines discuss nystatin dosing for oropharyngeal candidiasis (100,000 U/mL suspension 4-6 mL four times daily or 1-2 pastilles of 200,000 U each four times daily for 7-14 days) 6, these recommendations are for mucosal disease treatment, not peritoneal dialysis prophylaxis. The specific peritoneal dialysis prophylaxis regimen is derived from the dedicated research in this population 1, 2, 3.