What is the recommended treatment for oral candidiasis using Nystatin (nystatin) mouthwash?

Nystatin Mouthwash for Oral Candidiasis

For mild oral candidiasis, use nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, swishing thoroughly in the mouth for at least 2 minutes before swallowing, though clotrimazole troches or miconazole buccal tablets are preferred first-line alternatives due to superior convenience. 1, 2

Treatment Algorithm by Disease Severity

Mild Disease

• Preferred options: Clotrimazole troches 10 mg five times daily OR miconazole mucoadhesive buccal 50-mg tablet once daily for 7-14 days 1, 2
• Alternative (second-line): Nystatin suspension 4-6 mL four times daily OR nystatin pastilles 1-2 tablets (200,000 units each) four times daily for 7-14 days 1, 3
• The IDSA classifies nystatin as an alternative rather than first-line for mild disease, with strong recommendation but only moderate-quality evidence 1

Moderate to Severe Disease

• First-line: Oral fluconazole 100-200 mg daily for 7-14 days 1, 2
• Fluconazole achieves 87% clinical cure rates versus only 52% with nystatin in HIV-infected patients 2, 4
• Nystatin should NOT be used for moderate-to-severe disease due to inferior efficacy 2, 3

Critical Administration Technique

When nystatin is used, proper technique is essential:

• Swish the suspension thoroughly throughout the mouth for at least 2 minutes to ensure contact with all affected areas 2, 3
• Swallow the medication rather than spitting it out to treat potential esophageal involvement 2
• Continue treatment for the full 7-14 days, extending at least 48 hours after symptoms disappear 2
• For denture-related candidiasis, denture disinfection must accompany antifungal therapy 1, 2

Key Limitations of Nystatin

The evidence reveals significant drawbacks:

• Clinical cure rates as low as 32-54% compared to 100% with fluconazole in some populations 2, 3
• Mycological eradication rate of only 6% versus 60% with fluconazole 4
• Higher relapse rates (44% versus 18% with fluconazole at day 28) 4
• Should not be first-line for immunocompromised patients due to inferior efficacy 2, 3

Management of Treatment Failure

If nystatin fails after 7-14 days:

• Switch to itraconazole solution 200 mg once daily (effective in approximately two-thirds of fluconazole-refractory cases) 2, 3
• 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 1, 3

Special Populations

HIV-Infected Patients

• Antiretroviral therapy is strongly recommended to reduce recurrence rates, which is more important than the choice of antifungal 1, 2
• For recurrent infections requiring chronic suppression, use fluconazole 100 mg three times weekly rather than continuous nystatin 1, 3

Patients Unable to Tolerate Oral Therapy

• IV fluconazole 400 mg daily OR IV echinocandin (micafungin 150 mg daily, caspofungin 70 mg loading then 50 mg daily, or anidulafungin 200 mg daily) 1, 2

Common Pitfalls to Avoid

• Do not use nystatin as first-line for moderate-to-severe disease – fluconazole is superior 2, 3
• Do not spit out nystatin suspension – swallowing treats potential esophageal involvement 2
• Do not use nystatin for esophageal candidiasis – systemic therapy is always required 2
• Do not forget denture disinfection in denture-related candidiasis, as antifungal therapy alone is insufficient 1, 2
• Do not use inadequate swishing time – at least 2 minutes is necessary for adequate mucosal contact 2, 3