This question concerns general information on the treatment of oral and gastrointestinal candidiasi

Fråga: This question concerns general information on the treatment of oral and gastrointestinal candidiasis with nystatin. What is the risk of absorption?

Sammanfattning: Nystatin is a polyene antibiotic of choice against oral and intestinal Candida spp. infections. Nystatin is poorly absorbed from the gastrointestinal tract. Doses of 8000000 IU or more administered orally may give plasma levels of 1 to 2.5 ug/ml in individuals with normal renal function. Untoward effects of nystatin are uncommon and mild.

Svar: The agents that are used in the treatment of oral and intestinal candidiasis are the three structurally closely related polyene antibiotics: nystatin, amphotericin B and natamicin, and the imidazoles: clotrimazole, miconazole and ketoconazole (1,2,3,4). All of these are available in Sweden (5).

Nystatin is a polyene antibiotic formed by Streptomyces noursei. It can be either fungistatic or fungicidal. Its mode of action is the combination with sterols in the fungal membrane causing increased permeability and fatal leakage of cell constituents (6) specially of potassium ions, without which energy metabolism stops (4). Purification of nystatin is impractical, and it is usually prescribed in units, 3500 units being the activity of 1 mg of the pure substance (6).

Nystatin has a very low solubility and is poorly absorbed from the gastrointestinal tract. When single doses of 8000000 IU or more are given orally, individuals with normal renal function may have plasma levels of 1 to 2.5 ug/ml. Persons with renal insufficiency do not require dosage adjustment. Only nausea, vomiting and diarrhoea have been reported with oral administration of nystatin. It has a bitter and unpleasant flavour (4,7,8). No adverse reactions to nystatin given orally have been reported to the National Board of Health in Sweden.

For the treatment of oral and intestinal candidiasis in an adult rinses with 2 to 6 ml of an oral suspension of nystatin 100000 IU/ml for 1 to 2 minutes, four times in 24 hours, half of the dose in each side of the mouth may be adequate. This can either be spit out or swallowed (1,2,9,10). The usual therapeutic dosage of nystatin tablets is 1 to 2 tablets (500000 to 1000000 IU) four times in 24 hours (10). Nystatin popsicles are another alternative, four times daily, made by placing 2 ml of the oral suspension in each receptacle of an ice cube tray, filling the container and then freezing (9). Nystatin in vaginal tablets (2) or vaginal suppositories (9) or tablets (4) allowed to dissolve in the mouth four times a day are also recommended. For infants and young children nystatin drops, topical cream or suspension may be tried. The course of treatment lasts 10-14 days (2).