Oral nystatin is used for the treatment of certain infections of the GI tract caused by Candida, including oropharyngeal candidiasis and nonesophageal mucous membrane GI candidiasis. Nystatin should not be used for the treatment of systemic fungal infections.
Nystatin oral suspension is used for the treatment of candidiasis of the oral cavity (oropharyngeal candidiasis).
For the treatment of oropharyngeal candidiasis, the Infectious Diseases Society of America (IDSA) recommends topical treatment with clotrimazole lozenges or nystatin oral suspension for mild disease and systemic treatment with oral fluconazole for moderate to severe disease.
For the treatment of oropharyngeal candidiasis in adults and adolescents with human immunodeficiency virus (HIV) infection, the US Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and IDSA recommend oral fluconazole as the preferred drug of choice for initial episodes and topical treatment with clotrimazole lozenges or nystatin oral suspension as alternative drugs of choice. Topical treatment with clotrimazole lozenges or nystatin oral suspension also is recommended for early, uncomplicated oropharyngeal candidiasis in HIV-infected infants and children; however, oral fluconazole may be more effective for initial treatment in infants and is recommended if a systemic antifungal is considered necessary.
Nonesophageal Mucous Membrane GI Candidiasis
Nystatin tablets are used for the treatment of nonesophageal mucous membrane GI candidiasis. Systemic anti-infective therapy (e.g., oral or IV fluconazole, IV amphotericin B, IV echinocandin) is necessary for the treatment of esophageal candidiasis.
In patients with coexisting intestinal candidiasis and vulvovaginal candidiasis, nystatin has been administered orally in conjunction with intravaginal application of an antifungal. While early studies provided some limited evidence that, by reducing intestinal candidal colonization, combined oral and intravaginal antifungal therapy possibly could improve the mycologic response and reduce the recurrence rate of vulvovaginal candidiasis, most evidence suggests that combined therapy does not substantially reduce the risk of recurrence compared with intravaginal therapy alone.
Candidal Diaper Dermatitis
Nystatin oral suspension has been used in conjunction with topical application of the drug for the treatment of candidal diaper dermatitis. The majority of infants with candidal diaper dermatitis harbor C. albicans in their intestines, and infected feces appear to be an important source of the cutaneous infection. Candidal diaper dermatitis usually is treated with topical antifungaltherapy (e.g., topical nystatin, amphotericin B, miconazole, clotrimazole). In addition, some clinicians recommend that an oral antifungal(e.g., nystatin, fluconazole) be administered concomitantly to treat the intestinal infection. Despite the fact that results of 2 small studies have not provided evidence that concomitant oral and topical therapy is more effective than topical therapy alone, some clinicians suggest that such a strategy may be warranted.
Prevention of Fungal Infections in Transplant Recipients, Cancer Patients, or Other Patients at High Risk
Transplant Recipients and Patients with Cancer
Nystatin tablets or oral suspension have been used in various regimens for prophylaxis against Candida infections during periods of iatrogenic neutropenia in patients receiving immunosuppressive therapy (e.g., patients with malignancies, transplant recipients) with variable results. Use of primary antifungal prophylaxis against Candida infections in nonneutropenic patients or neutropenic cancer or transplant patients has been controversial, particularly since such prophylaxis may predispose the patient to colonization with resistant fungi and/or result in the emergence of highly resistant organisms.
While there is some limited evidence that oral nystatin prophylaxis may reduce the incidence of mucocutaneous candidiasis in some neutropenic patients, it is unlikely that the drug would decrease the frequency of invasive candidiasis. In addition, there is some evidence that oral fluconazole is more effective than oral nystatin for prophylaxis against Candida infections in immunocompromised patients. In one study in adult and pediatric liver transplant patients randomized to receive antifungal prophylaxis with nystatin oral suspension or oral fluconazole, Candida infections developed in 27% of those receiving nystatin and 12% of those receiving fluconazole (intent-to-treat analysis). Superficial Candida infections or documented systemic invasive Candida infections developed in 25.3 or 6%, respectively, of those receiving nystatin and in 10.5 or 1.3%, respectively, of those receiving fluconazole.
If primary prophylaxis against candidiasis is indicated in individuals with chemotherapy-induced neutropenia, the IDSA recommends fluconazole, posaconazole, or caspofungin during induction chemotherapy and continued for the duration of neutropenia. If postoperative antifungal prophylaxis is indicated in solid organ transplant recipients at high risk for invasive candidiasis (i.e., liver, pancreas, or small bowel transplant recipients), the IDSA recommends fluconazole or IV amphotericin B.
Low Birthweight Neonates
Oral nystatin has been used for prophylaxis to reduce the incidence of invasive candidiasis in low birthweight neonates at high risk. There is some evidence that nystatin prophylaxis can decrease the risk of colonization and reduce the incidence of invasive candidiasis in low birthweight neonates if initiated within 48 hours of birth; however, some studies indicate it is less effective than fluconazole for such prophylaxis and additional study is needed. Although antifungal prophylaxis in low birthweight neonates has been controversial, the American Academy of Pediatrics (AAP) and IDSA recommend oral fluconazole when such prophylaxis is used (e.g., in very low birthweight neonates weighing less than 1 kg in nurseries that have very high rates of neonatal invasive candidiasis).
For use of nystatin in the topical treatment of cutaneous candidiasis and vulvovaginal candidiasis and additional information on treatment of oropharyngeal candidiasis, see Nystatin 84:04.08.