Nystatin Dosing for Oral Thrush
For adults and children with mild oral thrush, 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
- Administer 4-6 mL (400,000-600,000 units) four times daily 1, 3, 2
- Place one-half of the dose in each side of the mouth 2
- Retain in mouth as long as possible (at least 2 minutes) before swallowing 1
- Continue for 7-14 days, extending at least 48 hours after symptoms resolve and cultures confirm Candida eradication 1, 2
Infants
- Use 2 mL (200,000 units) four times daily 2
- Use dropper to place one-half of dose in each side of mouth 2
- Avoid feeding for 5-10 minutes after administration 2
- For premature and low birth weight infants, 1 mL four times daily is effective 2
Alternative Formulation
Critical Administration Technique
Swallow the medication rather than spitting it out to treat potential esophageal involvement 1. This is a common pitfall—patients often assume they should spit out oral suspensions, but nystatin must be swallowed for optimal efficacy.
Timing: Ideally administer after meals and before bedtime 1
When Nystatin Is NOT Appropriate
Moderate to Severe Disease
Switch to oral fluconazole 100-200 mg daily for 7-14 days for moderate-to-severe oral thrush, as it demonstrates superior efficacy with 100% clinical cure rates compared to nystatin's 32-54% cure rates 1, 4
Immunocompromised Patients
Nystatin should not be first-line for immunocompromised patients due to lower efficacy compared to systemic azoles 1. Research demonstrates fluconazole achieves 91% clinical cure versus 51% with nystatin in immunocompromised children 5
Treatment Failure
If no clinical response within 48-72 hours, consider alternative diagnosis or resistant organisms 3. Switch to itraconazole solution 200 mg once daily, which is effective in approximately two-thirds of fluconazole-refractory cases 1
Special Considerations
Denture-Related Candidiasis
Denture disinfection must accompany nystatin therapy to prevent reinfection 1, 3
HIV-Infected Patients
Antiretroviral therapy is more important than antifungal choice for reducing recurrence rates 1. For chronic suppression, use fluconazole 100 mg three times weekly 1
Esophageal Involvement
Topical nystatin is inadequate for esophageal candidiasis—systemic therapy is required 1
Common Pitfalls to Avoid
- Do not use nystatin for moderate-to-severe disease—fluconazole is superior 1, 3
- Do not stop treatment when symptoms improve—continue full 7-14 day course and extend at least 48 hours after symptom resolution 1, 2
- Do not forget to address dentures in denture-related candidiasis 1, 3
- Do not expect high cure rates in immunocompromised patients—consider fluconazole instead 1, 5