Nystatin Dosing Recommendations
For oral candidiasis in adults and children, use nystatin suspension 4-6 mL (400,000-600,000 units) four times daily for 7-14 days, or nystatin pastilles 1-2 tablets (200,000 units each) four times daily for 7-14 days. 1
Oral Candidiasis
Adults and Children
- Nystatin suspension: 4-6 mL (400,000-600,000 units) swished in mouth four times daily for 7-14 days 1
- Nystatin pastilles: 1-2 tablets (200,000 units each) four times daily for 7-14 days 1
- The suspension must be swished thoroughly in the mouth for at least 2 minutes before swallowing to ensure contact with all affected areas 1
- Complete the full 7-14 day course even when symptoms resolve early 1
Infants
- Nystatin suspension (100,000 units/mL): 1 mL four times daily for 7-14 days 2
- Continue treatment for at least 48 hours after symptoms resolve and cultures confirm Candida eradication 2
Important caveat: Nystatin suspension has shown inferior efficacy compared to fluconazole in infants, with clinical cure rates of only 32% versus 100% for fluconazole in one trial 3. A systematic review confirmed nystatin suspension is not superior to fluconazole in infants, children, or HIV/AIDS patients 4.
Dosing Optimization
- Pastilles are more effective than suspension alone: Higher mycological cure rates are achieved with pastilles, particularly at 400,000 units versus 200,000 units 4
- Combination therapy: Using nystatin suspension and pastilles together for 2 weeks may achieve higher clinical and mycological cure rates than suspension alone 4
- Extended duration: Treatment with pastilles for 4 weeks appears more effective than 2 weeks for persistent cases 4
Neonatal Prophylaxis (High-Risk Settings)
Extremely Low Birth Weight Infants (<1500g)
- Nystatin prophylaxis: 100,000 units orally three times daily for 6 weeks 1, 2
- This regimen is recommended when fluconazole is unavailable or resistance precludes its use 1, 2
- Indicated in NICUs with invasive candidiasis rates >10% 2
Critical warning: Nystatin prophylaxis lowers invasive candidiasis incidence but does NOT reduce mortality and may increase the risk of necrotizing enterocolitis in premature infants 2. Monitor closely for intestinal complications 2.
Alternative for Prophylaxis
- Fluconazole 3-6 mg/kg twice weekly for 6 weeks is preferred when available, as it provides superior protection 2
Vulvovaginal Candidiasis
While specific dosing guidelines for vulvovaginal formulations were not detailed in the provided evidence, in vitro data shows nystatin maintains consistent activity (MIC90 of 4 mg/L) against both C. albicans and non-albicans Candida species 5. Nystatin may be particularly useful for non-albicans species that show reduced susceptibility to imidazoles 5.
Gastrointestinal Decontamination
The provided guidelines do not recommend nystatin for routine gastrointestinal decontamination 6. Therapy is not indicated for Candida isolated from the lower respiratory tract without histopathologic confirmation of invasive disease 6.
Cutaneous Candidiasis
For disseminated cutaneous candidiasis in premature or low birth weight neonates, systemic antifungal therapy is required, not topical nystatin 2. Use amphotericin B deoxycholate 0.5-1 mg/kg/day for a total dose of 10-25 mg/kg, or fluconazole 12 mg/kg daily for at least 3 weeks 2.
Special Considerations
Denture-Related Candidiasis
- Denture disinfection must accompany nystatin therapy for successful treatment 1
HIV-Infected Patients
- Antiretroviral therapy reduces recurrence rates in HIV patients with recurrent oral candidiasis 1
- Systemic therapy may be more appropriate than topical nystatin for this population 1
Breastfeeding-Associated Thrush
- Treat mother and infant simultaneously, with mother applying miconazole cream to nipples/areola after each feeding 2