Nystatin Lozenges for Oral Thrush
For mild oral thrush, use nystatin pastilles (lozenges) 1-2 pastilles (200,000 units each) four times daily for 7-14 days, though fluconazole is superior for moderate-to-severe disease. 1, 2
Dosing and Administration
Standard Dosing
- Nystatin pastilles: 1-2 lozenges (200,000 units each) four times daily for 7-14 days 1, 2
- Alternative formulation: Nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days 1, 3
- The medication must be retained in the mouth as long as possible before swallowing to maximize contact with affected mucosa 3
Treatment Duration
- Continue treatment for at least 48 hours after symptoms disappear and cultures confirm eradication of Candida albicans 3, 2
- Standard duration is 7-14 days 1, 2
Treatment Algorithm by Disease Severity
Mild Disease
- First-line: Nystatin pastilles 1-2 lozenges four times daily OR clotrimazole troches (10 mg 5 times daily) for 7-14 days 1, 2
- Miconazole mucoadhesive buccal tablets (50 mg once daily) offer more convenient once-daily dosing 2
Moderate-to-Severe Disease
- First-line: Oral fluconazole 100-200 mg daily for 7-14 days (strong recommendation; high-quality evidence) 1, 2
- Fluconazole demonstrates 100% clinical cure rates compared to only 32-54% with nystatin in comparative studies 2, 4
Important Clinical Caveats
Efficacy Limitations
- Nystatin has suboptimal tolerability and significantly lower efficacy compared to fluconazole, with clinical cure rates of only 32-51% versus 91-100% for fluconazole in immunocompromised patients 2, 4, 5
- Nystatin should not be first-line for moderate-to-severe disease or immunocompromised patients 2
Special Populations
- HIV-infected patients: Antiretroviral therapy is strongly recommended alongside antifungal treatment to reduce recurrence rates 1, 2
- Denture-related candidiasis: Denture disinfection must accompany antifungal therapy 1, 2
- Recurrent infections: Fluconazole 100 mg three times weekly for chronic suppression 1, 2
Management of Treatment Failure
Fluconazole-Refractory Disease
- Itraconazole solution 200 mg once daily for up to 28 days 1, 2
- Posaconazole suspension 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days 1, 2
- Voriconazole 200 mg twice daily OR amphotericin B deoxycholate oral suspension 100 mg/mL four times daily 1, 2
Patients Unable to Tolerate Oral Therapy
- Intravenous fluconazole 400 mg (6 mg/kg) daily 1, 2
- Intravenous echinocandin (caspofungin 70 mg loading dose then 50 mg daily, micafungin 150 mg daily, or anidulafungin 200 mg daily) 1, 2
Common Pitfalls
- Do not use nystatin for esophageal candidiasis—systemic therapy is always required 1, 2
- Nystatin requires four-times-daily dosing with prolonged oral contact, leading to poor adherence compared to once-daily fluconazole 2, 4
- Clinical response should be evident within 48-72 hours; if symptoms persist beyond 7 days, consider switching to fluconazole 2, 6