Corticosteroids are sometimes recommended for patients with sepsis, but their efficacy in patients hospitalized with community-acquired pneumonia is unclear. Most trials have been small, and their results have been inconsistent, showing both improvement and worsening in the clinical course of the disease. A recent Cochrane review (with 4 trials in 235 adults with pneumonia) suggested that hydrocortisone may reduce the need for mechanical ventilation, but found no significant mortality benefit with either hydrocortisone or prednisolone as adjunctive pneumonia treatment (Cochrane Database Syst Rev 2011 Mar 16;(3):CD007720). In a trial with 213 hospitalized patients with pneumonia, oral prednisolone was associated with increased treatment failure (defined as escalation in care) at > 72 hours after admission (19.2% vs. 9.2%, p = 0.04, NNH 10), again with no significant differences in mortality or in 7-day clinical cure rates (Am J Respir Crit Care Med 2010 May 1;181(9):975). Prednisone was associated with a trend toward lower 30-day clinical cure rates (66.3% vs. 77.1%, p = 0.08).
In the largest trial to date, 304 patients with community-acquired pneumonia were randomized to dexamethasone 5 mg IV vs. placebo once daily for 4 days. All patients received intravenous antibiotics within 4 hours of hospital admission. Dexamethasone was associated with a significant 1-day reduction in median hospital stay (6.5 days vs. 7.5 days, p = 0.048), but there were no significant differences in in-hospital mortality (5% vs. 5%), 30-day mortality (6% vs. 7%), intensive care admissions (5% vs. 7%), hospital readmissions (5% vs. 5%), or empyema or pleural effusion (5% vs. 3%) (level 2 [mid-level] evidence). There was a significant increase in the risk of hyperglycemia in the dexamethasone group (44% vs. 23%, p< 0.0001, NNH 4) (Lancet 2011 Jun 11;377(9782):2023). Considering all of these trials, corticosteroids have inconsistent evidence for improving or worsening clinical course in adults hospitalized with community-acquired pneumonia.
For more information, see the Pneumonia in adults topic in DynaMed.
Prunes May Be More Effective Than Psyllium for Constipation
Prunes (dried plums) have long been considered effective for constipation, and are the most common food that people associate with an anti-constipation effect. However, there has been little direct evidence to evaluate the efficacy of prunes as a dietary treatment or to compare prunes to other treatments for constipation. A recent trial, supported by the California Dried Plum Board, provides some comparative efficacy evidence (Aliment Pharmacol Ther 2011 Apr;33(7):822).
Forty adults (37 women) with chronic constipation were studied in a randomized crossover trial with blinding of the outcome assessors. Participants had mild to moderate constipation and patients with comorbidities, alarm symptoms, or irritable bowel syndrome were excluded. Treatment periods lasted 3 weeks separated by a 1-week washout period. One treatment period used prunes 50 g (about 6 prunes) twice daily with meals; the other treatment period used psyllium 11 g twice daily with 8 ounces of water. Prunes were more effective than psyllium using measures of number of complete spontaneous bowel movements (3.4 vs. 2.8 per week, p = 0.006) or stool consistency (p = 0.02). The most clinically relevant outcome (improvement in global constipation symptoms) was reported by 70% with prunes and by 55% with psyllium, but this was not statistically significant (level 2 [mid-level] evidence). There were not significant differences between treatments in palatability, satiety, bloating, or adverse events.
For more information, see the Constipation in adults topic in DynaMed.