|Systematic (IUPAC) name|
(1S,3R,4R,7R,9R,11R,15S,16R,17R,18S,19E,21E, 25E,27E,29E,31E,33R,35S,36R,37S)-33-[(3-amino-3, 6-dideoxy-β-L-mannopyranosyl)oxy]-1, 3,4,7,9,11,17,37-octahydroxy-15, 16,18-trimethyl-13-oxo-14, 39-dioxabicyclo[33.3.1]nonatriaconta-19,21,25,27,29,31-hexaene-36-carboxylic acid
|Trade names||generics only|
|Legal status||℞ Prescription only|
|Routes||topical & oral (but not absorbed)|
|Bioavailability||0% on oral ingestion|
|Metabolism||None (not extensively absorbed)|
|Half-life||Dependent upon GI transit time|
|ATC code||A07 D01 G01|
|(what is this?)|
Nystatin (originally named Fungicidin) is a polyene antifungal medication that is derived from a bacteria, Streptomyces noursei. It was discovered by Rachel Fuller Brown and Elizabeth Lee Hazen in 1950. Many molds and yeast infections are sensitive to nystatin, most notably Candida. It is used primarily for infections involving the skin, mouth, esophagus and vagina. Due to its toxicity profile when high levels in the serum are obtained, there are currently no injectable formulations of this drug on the US market. However, injectable formulations have been investigated in the past. Nystatin may be safely given orally as well as applied topically due to its minimal absorption through mucocutaneous membranes such as the gut and the skin.
It is on the World Health Organization's List of Essential Medicines, a list of the most important medication needed in a basic health system.
Cutaneous, vaginal, mucosal and esophageal Candida infections usually respond well to treatment with nystatin. Nystatin is available in many forms. Oral nystatin is often used as a preventative treatment in people who are at risk for fungal infections, such as AIDS patients with a low CD4+ count and patients receiving chemotherapy. It has been investigated for use in patients after liver transplantation but fluconazole was found to be much more effective for preventing colonization, invasive infection and death.
It is also used prophylactically in Very Low Birth Weight (<1500 g) infants to prevent invasive fungal infections, although fluconazole is the preferred agent. It has been found to reduce the incidence of invasive fungal infections and also reduce deaths when used in these babies. Current clinical practice guidelines state that the use of these agents should be restricted to extremely low birthweight infants (<1000g) in neonatal intensive care units with high baselines of fungal infection.
Liposomal Nystatin is not currently available but investigational use has shown greater in vitro activity than colloidal formulations of Amphotericin B, and demonstrated effectiveness against some Amphotericin B resistant forms of fungi. It offers an intriguing possibility for difficult to treat systemic infections, such as invasive aspergillosis, or infections that demonstrate resistance to Amphotericin B. Additionally, liposomal Nystatin appears to cause fewer cases of and less severe nephrotoxicity than observed with Amphotericin B. However, at the time of this writing, plans for additional development and investigation of liposomal nystatin appear in flux.
Cryptococcus is also sensitive to nystatin. In the UK its license for treating neonatal oral thrush is restricted to those over the age of one month (miconazole is an appropriate alternative for younger babies).
It is prescribed in units, with doses varying from 100,000 (for oral infections) to 1 million (for intestinal ones). As it is not absorbed from the gut, it is safe for oral use and does not have problems of drug interactions. Although occasionally, serum levels of the drug can be identified from oral, vaginal, or cutaneous administration and lead to toxicity.
In certain cases, nystatin has been used to prevent the spread of mold on objects such as works of art. For example, it was applied to wood panel paintings damaged as a result of the Arno River Flood of 1966 in Florence, Italy.
Nystatin is also used as a tool by scientists performing "perforated" patch-clamp electrophysiologic recordings of cells. When loaded in the recording pipette, it allows for measurement of electrical currents without washing out the intracellular contents, because it forms pores in the cell membrane that are permeable to only monovalent ions.
Mechanism of action
Like amphotericin B and natamycin, nystatin binds to ergosterol, a major component of the fungal cell membrane. When present in sufficient concentrations, it forms pores in the membrane that lead to K+ leakage, acidification, and death of the fungus. Ergosterol, is unique to fungi, so the drug does not have such catastrophic effects on animals or plants. However, many of the systemic/toxic effects of Nystatin are attributable to its effect on human cells via binding to mammalian sterols, namely cholesterol. This is the effect that accounts for the nephrotoxicity observed when high serum levels of Nystatin are achieved.
Nystatin A1 (or referred to as nystatin) biosynthesized by a bacterial strain, Streptomyces noursei. The structure of this active compound is characterized as a polyene macrolide with a deoxysugar D-mycosamine, an amino glycoside. The genomic sequence of nystatin reveals the presence of the polyketide loading module (nysA) six polyketide synthases modules (nysB, nysC, nysI, nysJ, and nysK), two thioesterase (nysK and nysE). Thus, it is evident that the biosynthesis of the macrolide functionality follows the polyketide synthase I pathway.
Following, the biosynthesis of the macrolide, the compound undergoes post-synthetic modifications, which are aided by the following enzymes: GDP-mannose dehydratase (nysIII), P450 monooxygenase (nysL and nysN), aminotransferase (nysDII), and glycosyltransferase (nysDI). The biosynthetic pathway is thought to proceed as shown to yield nystatin.
The oral suspension form produces a number of adverse effects including but not limited to:
- Abdominal pain
- Rarely, tachycardia, bronchospasm, facial swelling, muscle aches
Both the oral suspension and the topical form can cause:
- Hypersensitivity Reactions, including Stevens-Johnson syndrome in some cases 
- Rash, itching, burning
Like many other antifungals and antibiotics, nystatin is of bacterial origin. It was isolated from Streptomyces noursei in 1950 by Elizabeth Lee Hazen and Rachel Fuller Brown, who were doing research for the Division of Laboratories and Research of the New York State Department of Health. Hazen found a promising micro-organism in the soil of a friend's dairy farm. She named it Streptomyces noursei, after William Nourse, the farm's owner. Hazen and Brown named nystatin after the New York State Health Department Laboratory (now known as the Wadsworth Center) in 1954.
- An oral suspension form is used for the prophylaxis or treatment of oropharyngeal thrush, a superficial candidal infection of the mouth and pharynx.
- A tablet form is preferred for candidal infections in the intestines.
- Nystatin is available as a topical cream and can be used for superficial candidal infections of the skin.
- Additionally, A liposomal formulation of nystatin was investigated in the 1980s and into the early 21st century. The liposomal form was intended to resolve problems arising from the poor solubility of the parent molecule and the associated systemic toxicity of the free drug.
- Pediaderm AF Complete
- Nystan (oral tablets, topical ointment, and pessaries, formerly from Bristol-Myers Squibb)
- Nystalocal from Medinova AG
- Nystop (topical powder, Paddock)
- Nysert (vaginal suppositories, Procter & Gamble)
- Nystaform (topical cream, and ointment and cream combined with iodochlorhydroxyquine and hydrocortisone; formerly Bayer now Typharm Ltd)
- Nilstat (vaginal tablet, oral drops, Lederle)
- Korostatin (vaginal tablets, Holland Rantos)
- Mycostatin (vaginal tablets, topical powder, suspension Bristol-Myers Squibb)
- Mycolog-II (topical ointment, combined with triamcinolone; Apothecon)
- Mytrex (topical ointment, combined with triamcinolone)
- Mykacet (topical ointment, combined with triamcinolone)
- Myco-Triacet II (topical ointment, combined with triamcinolone)
- Flagystatin II (cream, combined with metronidazole)
- Nistatina (oral tablets, Antibiotice Iaşi)
- Nidoflor (cream, combined with neomycin sulfate and triamcinolone acetonide)
- Stamicin (oral tablets, Antibiotice Iaşi)
- Animax (veterinary topical ointment or cream; combined with neomycin sulfate, thiostrepton and triamcinolone acetonide)
- Dismukes, WE et al. Clinical Mycology. Oxford University Press. pp. 50–53.
- "WHO Model List of EssentialMedicines". World Health Organization. October 2013. Retrieved 22 April 2014.
- Pappas, PG; Kauffman CA; Andes D; et al. (2009). "Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America.". Clin Infect Dis 48: 503. doi:10.1086/596757. PMID 19191635.
- Akaike N, Harata N (1994). "Nystatin perforated patch recording and its applications to analyses of intracellular mechanisms". Jpn. J. Physiol. 44 (5): 433–73. doi:10.2170/jjphysiol.44.433. PMID 7534361.[dead link]
- Hammond, S.M. (1977). "Biological activity of polyene antibiotics.". Progress in medicinal chemistry 14 (105-179). PMID 345355.
- Fjaervik E, Zotchev SB (2005). "Biosynthesis of the polyene macrolide antibiotic nystatin in Streptomyces noursei". Appl. Microbiol. Biotechnol. 67 (4): 436–443. doi:10.1007/s00253-004-1802-4. PMID 15700127.
- Dewick, Paul M. (2009). Medicinal Natural Products: A Biosynthetic Approach (3rd ed.). UK: John Wiley & Sons Ltd. ISBN 0-471-97478-1.
- "Micromedex Detailed Drug Information". Retrieved Apr 1, 2014.
- "FDA approved package insert".
- Ana Espinel-Ingroff, Medical mycology in the United States: a historical analysis (1894-1996), Springer, 2003, p. 62.