What is the recommended dose of nystatin (antifungal medication) swish for an elderly male patient with oral candidiasis?

Nystatin Swish Dosing for Oral Candidiasis

For an elderly male patient with oral candidiasis, the recommended dose of nystatin suspension is 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, swished in the mouth as long as possible before swallowing. 1

Standard Dosing Protocol

• The FDA-approved dosing for adults is 4-6 mL (400,000-600,000 units) four times daily, with one-half of the dose placed in each side of the mouth. 1
• The suspension should be retained in the mouth for as long as possible (ideally at least 2 minutes) before swallowing to ensure adequate contact with all affected mucosal surfaces. 2, 3
• Swallow the medication rather than spitting it out to treat potential esophageal involvement, which can occur concurrently with oral candidiasis. 2, 3
• Treatment should continue for at least 48 hours after symptoms disappear and cultures confirm eradication of Candida albicans. 1

Treatment Duration

• The standard treatment duration is 7-14 days for mild oral candidiasis. 4, 2
• Extending treatment to 4 weeks may improve clinical efficacy compared to 2 weeks of therapy, particularly for more persistent cases. 5

Alternative Nystatin Formulations

• Nystatin pastilles can be used as an alternative at a dose of 1-2 pastilles (200,000 units each) four times daily for 7-14 days. 4, 2
• Combining nystatin suspension and pastilles may achieve higher clinical and mycological cure rates compared to using suspension alone. 2, 5
• The 400,000 IU pastille dose demonstrates significantly higher mycological cure rates than the 200,000 IU dose. 5

Critical Limitations of Nystatin in Elderly Patients

Nystatin has significant limitations that must be considered, particularly in elderly or immunocompromised patients:

• Clinical cure rates with nystatin are only 32-54% compared to 100% with fluconazole in certain populations, making it suboptimal for moderate-to-severe disease. 2, 3
• Nystatin should NOT be first-line therapy for moderate-to-severe oral candidiasis or immunocompromised patients due to inferior efficacy. 2, 3
• For moderate-to-severe disease, oral fluconazole 100-200 mg daily for 7-14 days is superior and should be used instead. 4, 2

When to Escalate Therapy

Switch from nystatin to systemic therapy if:

• The patient has moderate-to-severe disease at presentation (use fluconazole 100-200 mg daily instead). 4, 2
• No clinical improvement occurs after 7-14 days of nystatin therapy. 2, 3
• The patient is immunocompromised (HIV/AIDS, chemotherapy, transplant recipient). 2
• For fluconazole-refractory disease, use itraconazole solution 200 mg daily, posaconazole suspension 400 mg twice daily for 3 days then 400 mg daily, or voriconazole 200 mg twice daily. 4, 3

Important Caveats for Elderly Patients

• Some commercial nystatin formulations contain sugar, which can promote dental caries and worsen denture stomatitis—sugar-free formulations should be preferred when available. 6
• For denture-related candidiasis (common in elderly patients), denture disinfection must accompany antifungal therapy or recurrence is likely. 4, 2
• Poor taste and gastrointestinal adverse effects are the most common side effects of nystatin. 5
• Reinfection rates are high after nystatin discontinuation, with approximately 80% of patients showing persistent Candida hyphae despite clinical improvement. 7, 8

Optimal Administration Timing

• Administer nystatin four times daily, ideally after meals and before bedtime, to maximize mucosal contact time. 2
• Avoid eating or drinking for 5-10 minutes after administration to prevent premature clearance. 1