Nystatin Dosing and Treatment for Fungal Infections
For mild oropharyngeal candidiasis, nystatin suspension 400,000-600,000 units (4-6 mL) four times daily or nystatin pastilles 200,000 units (1-2 pastilles) 4-5 times daily for 7-14 days is recommended as an alternative to topical azoles, though fluconazole is superior for moderate-to-severe disease. 1
Oropharyngeal Candidiasis Dosing
Mild Disease
- Nystatin suspension (100,000 U/mL): 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
- The preparation should be retained in the mouth as long as possible before swallowing 2
- Continue treatment for at least 48 hours after symptoms disappear and cultures confirm eradication 2
Pediatric Dosing
- Infants: 2 mL (200,000 units) four times daily using dropper to place half the dose in each side of mouth; avoid feeding for 5-10 minutes 2
- Premature/low birth weight infants: 1 mL four times daily is effective 2
- Children: 4-6 mL (400,000-600,000 units) four times daily 2
Important Caveats
- Nystatin is positioned as an alternative agent, not first-line therapy 1
- Clotrimazole troches or miconazole buccal tablets are preferred topical options with stronger evidence 1
- For moderate-to-severe oropharyngeal candidiasis, oral fluconazole 100-200 mg daily for 7-14 days is superior 1
Vulvovaginal Candidiasis
C. glabrata Infection (Azole-Refractory)
- Nystatin intravaginal suppositories: 100,000 units daily for 14 days 1
- This is recommended specifically for C. glabrata vulvovaginitis unresponsive to oral azoles 1
- Topical intravaginal boric acid 600 mg daily for 14 days is the preferred alternative 1
Cutaneous Candidiasis
Skin Infections and Intertrigo
- Topical nystatin cream is effective for nonhematogenous primary skin infections, particularly intertrigo in skin folds 1
- Keeping the infected area dry is equally important as antifungal therapy 1
- For recurrent groin candidiasis with persistent moisture (wheelchair-bound, incontinence), apply topical azole cream twice daily for 14 days, then once daily maintenance therapy 3
Severe Burn Wounds
- Nystatin powder (6,000 units/g) has been used successfully for angioinvasive fungal infections in severely burned patients 4
- This is reserved for refractory cases where other topical and systemic agents have failed 4
Prophylaxis in High-Risk Populations
Very-Low-Birthweight Infants
- Prophylactic oral nystatin: 1 mL (100,000 units/mL) every 8 hours until 1 week after extubation reduces fungal colonization and systemic infection 5
- This significantly decreases both colonization (12% vs 44%) and systemic infection (6% vs 32%) compared to no prophylaxis 5
Leukemia Patients
- Nystatin is NOT recommended for prophylaxis in severely immunodepressed patients 6
- Fluconazole 200 mg daily is significantly more effective than nystatin 6,000 IU daily for preventing fungal infections during chemotherapy 7, 6
- Nystatin showed no benefit over placebo for fungal colonization in immunocompromised patients 6
Efficacy Considerations
Evidence-Based Dosing Strategies
- Nystatin pastilles alone or combined with suspension are more effective than suspension alone 8
- Higher pastille doses (400,000 IU) achieve better mycological cure rates than 200,000 IU 8
- Extended treatment duration (4 weeks) appears more effective than 2 weeks for pastilles 8
- Nystatin pastille is superior to placebo for denture stomatitis but not superior to fluconazole for oral candidiasis in HIV/AIDS patients 8
Common Pitfalls
- Do not use nystatin for esophageal candidiasis: Topical therapy is ineffective; systemic azoles or IV amphotericin B are required 1
- Avoid nystatin monotherapy in immunocompromised adults: Fluconazole or other systemic azoles are superior 7, 6
- Poor taste and gastrointestinal adverse effects are the most common side effects limiting compliance 8
- Nystatin has no role in treating candidemia or invasive candidiasis: Systemic therapy with echinocandins or azoles is mandatory 1