Nystatin Oral Rinse Dosing for Oral Candidiasis
For adults and children with mild oral candidiasis, use nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, swishing in the mouth as long as possible before swallowing. 1, 2
Standard Dosing by Age Group
- Adults and children: 4-6 mL (400,000-600,000 units) four times daily, with half the dose placed in each side of the mouth 2
- Infants: 2 mL (200,000 units) four times daily, using a dropper to place half the dose in each side of the mouth, avoiding feeding for 5-10 minutes 2
- Premature and low birth weight infants: 1 mL four times daily has been shown effective in limited studies 2
Alternative Nystatin Formulation
- Nystatin pastilles: 1-2 pastilles (200,000 units each) four times daily for 7-14 days can be used as an alternative to the suspension 1
Critical Administration Technique
- Swish the suspension thoroughly in the mouth for as long as possible (at least 2 minutes) to ensure contact with all affected areas 3
- Swallow the medication rather than spitting it out to treat potential esophageal involvement 3
- Continue treatment for at least 48 hours after symptoms disappear and cultures confirm eradication of Candida albicans 2
When NOT to Use Nystatin
For moderate to severe oral candidiasis, nystatin is inadequate—use oral fluconazole 100-200 mg daily for 7-14 days instead. 1 This recommendation is based on strong evidence showing fluconazole achieves 87% clinical cure rates versus only 52% with nystatin in HIV-infected patients 4, and clinical cure rates as low as 32-54% with nystatin compared to 100% with fluconazole in some populations 3.
- Nystatin should not be first-line for immunocompromised patients or those with moderate-to-severe disease due to inferior efficacy 3
- For esophageal candidiasis, systemic therapy is always required—topical nystatin is inadequate 3
Common Pitfalls to Avoid
- Low concentration formulations may fail: One study using 4,000 U/mL nystatin rinse (lower than standard 100,000 U/mL) showed no clinical or antifungal effect, suggesting concentration matters 5
- Denture-related candidiasis requires adjunctive therapy: Denture disinfection must accompany antifungal treatment, as antimicrobial therapy alone leads to rapid reinfection 1, 6
- Patient compliance is problematic: Half of patients report inconvenience with nystatin's four-times-daily dosing compared to once-daily fluconazole 7
Management of Treatment Failure
If nystatin fails after 7-14 days:
- Switch to itraconazole solution 200 mg once daily, which is effective in approximately two-thirds of fluconazole-refractory cases 3
- Alternative options for refractory disease: 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 1
- For severe refractory disease: IV echinocandins (caspofungin 70 mg loading then 50 mg daily, micafungin 100-150 mg daily, or anidulafungin 200 mg loading then 100 mg daily) or IV amphotericin B deoxycholate 0.3 mg/kg daily 1
Special Populations
- HIV-infected patients with recurrent infections: Antiretroviral therapy is strongly recommended to reduce recurrence rates, which is more important than the choice of antifungal 1, 3
- Chronic suppressive therapy: For patients with recurrent infections, fluconazole 100 mg three times weekly is recommended rather than continuous nystatin 1