Nystatin Intravaginal Dosing for Vaginal Candida glabrata
Nystatin intravaginal suppositories should be prescribed at 100,000 units daily for 14 days for vaginal Candida glabrata infection, though azole alternatives are generally preferred for this species. 1
Critical Context: Nystatin is Not First-Line for C. glabrata
The most important consideration is that nystatin is specifically listed as less effective than azole drugs for vulvovaginal candidiasis in general 1. However, for C. glabrata specifically—which is often azole-resistant—nystatin becomes a valuable alternative option.
Evidence-Based Treatment Approach for C. glabrata:
First-Line Options (per IDSA 2016 guidelines):
- Intravaginal boric acid (600 mg daily for 14 days) 2
- Nystatin intravaginal suppositories 2
- Topical 17% flucytosine cream alone or combined with 3% amphotericin B cream 2
Nystatin Specific Dosing:
- 100,000 units intravaginally daily for 14 days 1
- For recurrent C. glabrata: 14 days each month as maintenance therapy 3
Clinical Efficacy Data
Research demonstrates that nystatin achieves 64.3% mycological cure rates for C. glabrata vulvovaginal candidiasis, compared to only 12.5% with fluconazole 3. This makes nystatin substantially superior to azoles for this specific species.
For fluconazole-resistant Candida (which frequently includes C. glabrata), nystatin achieved successful treatment in 5 of 9 patients (56%) where fluconazole failed in all 7 patients (0%) 3.
Important Clinical Caveats
Common Pitfall: Do not assume all vulvovaginal candidiasis responds equally to treatment. C. glabrata requires species-specific therapy, and using standard short-course azoles will likely fail 2, 3.
Duration Matters: Single-dose or 3-day regimens are inappropriate for C. glabrata. The full 14-day course is essential for adequate response 1, 3.
Combination Therapy Consideration: In refractory cases, combining oral and vaginal nystatin may improve outcomes, as demonstrated in case reports of persistent C. glabrata infection 4.
Availability Issue: Nystatin intravaginal preparations may not be available in all countries (e.g., no longer available in the UK as of 2010) 5. In such cases, amphotericin and flucytosine vaginal cream achieved 100% clearance of non-albicans species in 18 patients 5.
Maintenance Therapy for Recurrent Infection
If recurrence occurs after initial treatment, nystatin 100,000 units intravaginally for 14 days each month can be used as maintenance therapy 3. However, expert consensus suggests that twice-weekly dosing is more commonly utilized for maintenance, though specific nystatin maintenance dosing is less well-established than for azoles 6.