Pneumococcal meningitis …

Ravindra Kumar Garg DM

Infectious Disorders

Updated 07.12.2025
Released 05.02.2005
Expires For CME 07.12.2028

Pneumococcal meningitis

Author: Ravindra Kumar Garg DM

See Contributor Disclosures

Editor: Christina M Marra MD

Cite this article

Pneumococcal meningitis

In This Article

Quick Link

Introduction

Overview

Streptococcus pneumoniae is the leading cause of bacterial meningitis in adults in the United States and accounts for significant morbidity and mortality in all age groups. Prompt recognition and treatment can improve outcomes. Treatment guidelines in adults recommend that dexamethasone be added to initial empiric antibiotic therapy. Administration of dexamethasone within 12 hours of initiating antibiotics reduced 30-day mortality in children with pneumococcal meningitis by 61%. Cerebral vasculitis is a significant complication observed in approximately one third of patients with pneumococcal meningitis. This article addresses current diagnostic laboratory techniques and provides up-to-date treatment recommendations based on the most recent research and expert opinions, research regarding the importance of endocarditis and bacteremia to neuropathogenesis, and the effect of bacterial meningitis on neurogenesis.

Key points

	• Globally, community-acquired bacterial meningitis is most frequently caused by Streptococcus pneumoniae.
	• Patients with a basilar skull or cribriform fracture with a CSF leak are at increased risk of acquiring pneumococcal meningitis.
	• CSF infection with Streptococcus pneumoniae often leads to severe meningeal inflammation.
	• Pneumococcal meningitis is treated intravenously with a combination of a third-generation cephalosporin and vancomycin.
	• Dexamethasone reduces mortality.
	• Dexamethasone treatment leads to lower rates of hearing loss.

Historical note and terminology

In 1881, Streptococcus pneumoniae was identified simultaneously by Pasteur in France, who named it Microbe septice mique du salive, and by Sternberg in the United States, who called it Micrococcus pasteuri. By the late 1880s, the term pneumococcus had come into general use because of the association between this organism and lobar pneumonia. In 1926, the term Diplococcus was assigned because of the organism’s appearance in gram-stained sputum. Finally, in 1974, the organism was renamed Streptococcus pneumoniae because of its morphology during growth in liquid medium (105; 68).

Clinical manifestations

Presentation and course

Streptococcus pneumoniae infections are more common in children and people over 65 years of age. S pneumoniae is a causative agent for many serious systemic infections, including pneumonia, septicemia, sinusitis, and otitis media (22; 61). The most frequent predisposing and associated conditions for pneumococcal meningitis are pneumonia, sinusitis, or otitis media. Invasive pneumococcal disease is defined as the isolation of Streptococcus pneumoniae by culture or PCR from a normally sterile site, such as blood or cerebrospinal fluid, confirming systemic infection (Department of Health, Victoria Australia 2025) (16).

Pneumococcal meningitis symptoms typically include fever, headache, nausea, vomiting, irritability, and lethargy proceeding to further clouding of consciousness. Fever may be 103°F or higher. Clinical signs include evidence of meningeal irritation, though this can be lacking in children, the elderly, and the deeply comatose. Focal signs may also appear. The course is frequently fulminant, with rapid neurologic deterioration leading to respiratory arrest and death (25; 100).

Lobar pneumonia and meningitis are the two most serious forms of S pneumoniae infection. Lobar pneumonia affects more people and, therefore, causes more morbidity and mortality, whereas meningitis has a higher mortality rate. S pneumoniae is the most common cause of bacterial meningitis in adults worldwide. In people over the age of 16, Streptococcus pneumoniae is responsible for approximately 72% of bacterial meningitis cases, whereas Neisseria meningitidis accounts for around 11%. In early-onset neonatal meningitis, Escherichia coli and Streptococcus agalactiae together make up about 35% of cases (68; 42). S pneumoniae is also a frequent cause of recurrent bacterial meningitis in individuals with a dural defect.

Finally, as a respiratory pathogen, the most typical coexisting complications will affect the upper or lower airways. Concomitant pneumonia is frequent in patients with S pneumoniae meningitis. Not infrequently, it is possible to obtain a history of productive cough, dyspnea, and constitutional symptoms in the days prior to onset of meningitis-like symptoms. Bacteria and inflammatory exudate accumulate in the alveoli of the lung, allowing a diagnosis of pneumonia to be made when a consolidated area appears on chest x-ray (68). The more severe cases of pneumonia are more likely to be accompanied by bacteremia (72; 104) and, therefore, with meningitis. Meningitis occurs in approximately 8% of patients who become bacteremic with this organism (83).

S pneumoniae is a common etiologic agent of otitis media in both children and adults (88; 31) and is either the first or second leading cause of acute sinusitis (41). In a study of 2548 episodes of community-acquired bacterial meningitis, otitis was present in 27% of cases, with Streptococcus pneumoniae identified as the primary pathogen in 88% (81). Otitis was associated with a favorable outcome (odds ratio 0.74), but ear surgery showed no significant impact on patient outcomes. These infections can provide a source of meningitis by either hematogenous spread or direct extension. It is reasonable to perform an otologic examination on any patient presenting with fever and altered consciousness (73).

The triad of pneumococcal pneumonia, meningitis, and endocarditis is a rare but serious condition known as Austrian syndrome (49). Alcoholism is the most common predisposing factor, but it is also seen with intravenous drug use (08), and the diagnosis of endocarditis should be considered early in every patient with pneumococcal meningitis or bacteremia (60).

Other complications of S pneumoniae include septic arthritis and osteomyelitis (35), both of which are manifestations of bacteremic spread, as is meningitis. Osteomyelitis also tends to involve the vertebral bones (99) and, from there, can extend directly into the central nervous system.

Prognosis and complications

The prognosis of Streptococcus pneumoniae meningitis, as with most bacterial meningitis, relates directly to early diagnosis and prompt initiation of appropriate antibiotic therapy (07). Streptococcus pneumoniae was the leading cause of meningitis-related deaths in 2019, accounting for 18.1% of all meningitis deaths (36). Morbidity, however, is high, even with the best possible treatment, and significant, permanent neurologic sequelae are observed in up to a third of the survivors (65; 07; 91). After pneumococcal meningitis, adult patients are at greater risk of neurologic and neuropsychologic deficits, impaired daily activities, and poor quality of life (52).

In a French study of 316 children with pneumococcal meningitis, the mortality rate was approximately 10%, and additionally, 23% of cases had severe complications (abscess, coma, hemodynamic failure, cerebral thrombophlebitis, or deafness) (43). In a U.S. retrospective study of in-patient data from 2008 to 2014, there were 10,493 hospitalizations due to pneumococcal meningitis. Data collected involved patients from all age groups (children younger than 2 years of age to over 65 years of age). Between 2008 and 2014, there were 1016 reported deaths, with the case fatality rate varying between 8.3% and 11.2% (48).

Acute neurologic complications, especially coma, are associated with later behavioral and developmental difficulties, developmental delay, hearing loss, motor defects, and seizures (78). Independent predictors of a poor outcome include low Glasgow coma scale score, presence of a cranial nerve palsy, elevated sedimentation rate (106), advanced age, presence of an underlying chronic illness, presence of pneumonia, absence of associated otitis media, seizures, requirement for assisted ventilation, high CSF protein concentration, low CSF glucose concentration, CSF white count below 500 cells/microliter (74; 55), abnormal deep tendon reflexes, presence of stroke or hydrocephalus on imaging, and delay in antibiotic administration (91).

Complications during acute illness are similar to those seen with meningitides of any etiology and include subdural effusion, empyema, ischemic or hemorrhagic stroke, cerebritis, ventriculitis, abscess, and hydrocephalus (40; 68). Hearing loss is the most common long-term neurologic sequela of pneumococcal meningitis, occurring in up to 35% of pediatric survivors (55). The pneumococcal toxin pneumolysin is an important factor involved in ototoxic toxicity (77). Other focal neurologic deficits, such as ataxia and paresis, occur in an additional 16% (74). In a 2024 multicenter study of adults with severe pneumococcal meningitis requiring ICU care, neuroimaging revealed complications in 31% at admission and 68% during ICU stay, with ischemic lesions (29%), cerebral edema (18%), and ventriculitis (15%) being most common. Intracranial complications independently predicted unfavorable outcomes. These findings emphasize the importance of early neuroimaging to detect complications that significantly affect prognosis, including persistent disability or death (57).

Cerebral vasculitis is a significant complication observed in approximately 29% of patients with pneumococcal meningitis as per a retrospective study conducted across two tertiary hospitals from 2002 to 2020. The study found that cerebral vasculitis was likely to occur when there was a delay in hospital admission after the first symptoms, with an increased risk noted for those having high CRP levels at admission and those who took NSAIDs before hospitalization. Furthermore, elevated CSF protein levels were also identified as a risk factor for cerebral vasculitis. Interestingly, the administration of dexamethasone showed no influence on the occurrence of cerebral vasculitis in patients with pneumococcal meningitis (06).

In contrast to acute vasculitis in individuals with acute pneumococcal meningitis, delayed cerebral vasculopathy associated with dexamethasone use is a slower, less immediate condition affecting the cerebral arteries. Boix-Palop and colleagues noted delayed cerebral vasculopathy in approximately 10% of patients with pneumococcal meningitis (09). Delayed cerebral vasculopathy was considered if these patients had clinical worsening or if they failed to show an expected improvement after beginning antibiotic treatment. Neuroimaging in these patients showed small or large cerebral vessel disease. The patients who had delayed cerebral vasculopathy were severely ill, had a longer duration of illness, and more frequently had unfavorable outcomes. The authors hypothesized that the abrupt withdrawal of corticosteroids led to a cascade of rebound inflammatory changes manifesting as vasculopathy.

A 2020 study of the long-term neurologic, cognitive, and quality-of-life outcomes in adults who survived pneumococcal meningitis (52) found that 1 to 5 years after the acute illness, 34% of patients exhibited persistent neurologic issues, predominantly hearing loss. Cognitive impairments were also significant, affecting domains like alertness and cognitive flexibility. The study also reported that these survivors had considerably lower quality-of-life scores compared to a control group.

Clinical vignette

A 45-year-old man with alcoholism was brought by ambulance from a homeless shelter to an emergency room due to alteration in mental status. A few hours earlier, he had told the staff at the shelter that he had a bad headache. He had also vomited once. He then went to rest on his bunk. When staff checked on him, they found him to be confused. In the emergency room, he was noted to have a temperature of 39.1 degrees Celsius. He responded to his first name but was not oriented to place or time. He was given doses of ceftriaxone, vancomycin, and ampicillin. A head CT was unremarkable, and a lumbar puncture was performed. CSF examination demonstrated an opening pressure of 500 mmHg, a white count of 4914 cells/ul with 91% neutrophils, a glucose concentration of 5 mg/dl, and a protein concentration of 279 mg/dl. Gram stain revealed gram positive diplococci, and a presumptive diagnosis of pneumococcal meningitis was made.

The patient was admitted to the neurologic intensive care unit. Triple antibiotic coverage was continued pending definitive speciation and antibiotic sensitivity determination. Intravenous dexamethasone was also added to the regimen. The patient’s condition continued to deteriorate, and he required ventilatory support. A repeat head CT demonstrated worsening cerebral edema. The patient developed signs of cerebral herniation. He was temporarily stabilized but then required pressor support. He became increasingly bradycardic, and eventually died, 30 hours after initial presentation.

CSF and blood cultures both confirmed the diagnosis of infection with Streptococcus pneumoniae, sensitive to all tested antibiotics.

Biological basis

Etiology and pathogenesis

S pneumoniae represents the classic extracellular bacterial pathogen. In the absence of anticapsular antibodies, it avoids phagocytosis and thrives in the extracellular environment. These gram-positive cocci typically grow in chains, are catalase-negative, and demonstrate improved growth when catalase is present, such as that found in red blood cells. The organism produces pneumolysin, which breaks down hemoglobin and results in a green discoloration on blood agar, a phenomenon termed alpha-hemolysis. To date, more than 100 serotypes have been recognized, each differentiated by the structure and antigenic properties of their polysaccharide capsule. However, a limited subset of these serotypes accounts for most invasive pneumococcal diseases (68; 18; 103). Importantly, serotype-specific differences affect host immune response, resulting in variability in pathogenesis, disease presentation, and outcomes (87). For instance, serotype 15B/C is more commonly implicated in meningitis among children, whereas serotype 12F is more frequently seen in adult meningitis. Additionally, serotype 15B/C shows notable resistance to antibiotics, such as penicillin and macrolides (67).

S pneumoniae colonizes the nasopharynx and may spread locally to the upper and lower respiratory tracts or disseminate to distant sites, including the central nervous system, via hematogenous routes. An autopsy study in children who died from bacterial meningitis found no evidence of direct extension from local infections, suggesting that hematogenous dissemination, even from otitis media, is often responsible for central nervous system involvement (32). Bacteremia may itself contribute to neurologic injury by disrupting cerebral blood flow, increasing blood-brain barrier permeability, and promoting cerebral edema (10; 76).

A major virulence determinant of S pneumoniae is its polysaccharide capsule, which facilitates immune evasion and inhibits phagocytosis. The capsule may physically repel immune cells and obscure antigenic structures on the bacterial surface (68). Genetic variability in the pneumococcal genome also influences the clinical manifestations of invasive disease. For example, the presence of the slaA gene and sequence cluster 9 have been independently linked with a predisposition for meningitis. Furthermore, a set of four genes located on a prophage has been shown to independently predict a higher risk of 30-day mortality in invasive pneumococcal disease (24).

Multiple bacterial and host factors influence the pathogenicity of S pneumoniae in the central nervous system. The intense inflammatory response elicited by the host plays a key role in tissue damage. The exact mechanisms by which the bacteria penetrate the blood-brain barrier remain incompletely understood. Once inside the cerebrospinal fluid, the bacteria multiply, eventually undergoing lysis. This process releases numerous toxic components, including pneumolysin, bacterial cell wall fragments, and capsular materials, which in turn trigger a profound inflammatory reaction in both the CSF and brain tissue (94; 47).

Pneumolysin activates the complement system, intensifying inflammation, yet paradoxically hampers complement function by binding to its proteins and damaging host cells. Although in much lower concentrations than in serum, complement proteins are present in the CSF, especially in meningitis. This dual action helps the bacteria evade immune clearance, thereby enhancing survival and replication within the host (26). Pneumolysin also damages phagocytes, triggers proinflammatory cytokines, and induces apoptosis-like cell death in both neurons and endothelial cells (62; 85). Disruption of the blood-brain barrier may also be linked to imbalances in matrix metalloproteinase (MMP-9) and its inhibitor TIMP-1 (89), whereas upregulation of aquaporin-4 increases water permeability, contributing to brain edema (75).

In response to central nervous system infection, neural progenitor cells undergo proliferation and differentiation. However, pneumococcal cell wall components may provoke immune activation that impairs neurogenesis (44). Murine studies have shown increased brain-derived neurotrophic factor (BDNF) and its receptor TrkB in the hippocampus during infection, suggesting a possible neuroprotective response (95), supported by in vitro findings of BDNF's protective effects (58).

Histopathological analyses of 31 fatal cases of pneumococcal meningitis revealed arterial inflammation, hemorrhage, cerebritis, thrombosis, infarctions, and ventriculitis. Vascular inflammation often resulted in occlusion and infarction (34). In another study, autopsies of two patients with cerebral venous thrombosis secondary to pneumococcal meningitis showed deep venous inflammation with bacterial presence in the thrombus, changes not observed in controls without meningitis (29). Delayed cerebral thrombosis in pneumococcal meningitis likely arises from combined vascular inflammation, thromboembolism, and infectious aneurysm formation, perpetuated by ongoing inflammation (33).

Epidemiology

Streptococcus pneumoniae is the leading cause of bacterial meningitis in the United States and in other parts of world. Infants and young children are particularly vulnerable for Streptococcus pneumoniae meningitis.

Bacterial meningitis incidence in the U.S. has declined since 2008, with Streptococcus pneumoniae remaining the leading cause across all age groups (59% of cases). The decline from 2008 to 2019 was largely due to reduced pneumococcal meningitis from vaccine-covered serotypes. A marked drop occurred during 2020–2021, coinciding with reduced S pneumoniae incidence, but rates rose again in 2022–2023. Despite these trends, mortality remained high at 11%. The decline was largely attributed to reductions in respiratory bacterial pathogens like Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, due to nonpharmaceutical interventions, such as mask-wearing, physical distancing, and reduced social interactions (79).

In 2019, S pneumoniae was the leading cause of meningitis-related deaths globally, accounting for 18.1% of all-age fatalities. N meningitidis (13.6%) and K pneumoniae (12.2%) followed closely. Among children under 5, S pneumoniae was responsible for 17.3% of meningitis deaths (36).

Between 2012 and 2019 in England, a study collected 6554 laboratory-confirmed cases of bacterial meningitis, with an annual incidence of 1.49 per 100,000. The primary pathogens were Streptococcus pneumoniae (19.9%), Neisseria meningitidis (12.2%), and Staphylococcus aureus (11.5%). Interestingly, while pneumococcal meningitis showed an increasing trend, meningococcal and group A streptococcal meningitis declined. Infants under 3 months had the highest incidence due to group B streptococci, whereas children aged 3 to 11 months mainly had pneumococcal and meningococcal infections. The overall 30-day fatality rate was 10%, but group A streptococcal meningitis had a staggering 55.3% mortality rate. Variations arise from differences in healthcare access, care-seeking behavior, antibiotic resistance, vaccination coverage, public health infrastructure, and microbial diversity, including regional serotype prevalence and emergence of non-vaccine strains (93).

Individuals with certain underlying conditions are at increased risk for pneumococcal infections. These include those with asplenia or splenic dysfunction (such as sickle cell disease); immunocompromised states like HIV infection, cancer, or post-organ transplantation; and chronic illnesses, such as diabetes mellitus and chronic heart, lung, liver, or kidney disease. Additional risk factors include alcoholism, cerebrospinal fluid leaks, the presence of cochlear implants, smoking, and advanced age, particularly individuals aged 65 years and older (37; 39; 03; 19). Certain ethnic groups, including Native Americans, Alaskans, and Australian Aboriginals, may have an incidence as much as 10-fold greater than the general population (27; 97; 50). The reasons for this remain unclear. Infants (but not neonates) up to 2 years of age and adults over 65 years are also at increased risk (11).

Transmission can occur due to close contact, such as in daycare centers, military camps, prisons, homeless shelters, and nursing homes (66; 45; 69; 90). The lockdown and COVID-19 containment measures had a favorable impact on the transmission of life-threatening invasive diseases caused by S pneumoniae, H influenzae, and N meningitidis globally. The reported incidence of S pneumoniae infections decreased by 68% at 4 weeks and 82% at 8 weeks after start of the lockdown (March 2020) (12).

Prevention

The Centers for Disease Control and Prevention (CDC) recommends routine pneumococcal vaccination for individuals at increased risk of infection or complications. This includes immunocompetent people with chronic pulmonary or cardiovascular disease, diabetes mellitus, alcoholism, liver or renal disease, cerebrospinal fluid leaks, or cochlear implants, as well as those aged over 65 years or under 2 years. Vaccination is also advised for immunocompromised individuals, such as those with functional or anatomic asplenia (eg, sickle cell disease); congenital or acquired immunodeficiencies; malignancies, including leukemia and lymphoma; HIV infection; or recipients of organ transplants. Additionally, vaccination may be appropriate for other at-risk groups, including Native Americans and individuals living in crowded settings (68; 20).

Pneumococcal conjugate vaccines are now part of national immunization programs of many countries (22). There are two types of pneumococcal vaccines currently available: pneumococcal conjugate and pneumococcal polysaccharide vaccine. The polysaccharides are conjugated to a carrier protein, which makes them more immunogenic and effective in protecting against infection, particularly in young children less than 2 years of age. Furthermore, the conjugate vaccines, not the polysaccharide vaccine, are effective at reducing nasopharyngeal colonization and, thus, lowering community transmission.

The Advisory Committee on Immunization Practices (ACIP) under the CDC has updated its recommendations for pneumococcal vaccinations in U.S. In the U.S., two pneumococcal vaccines, pneumococcal conjugate (PCV13, PCV15, or PCV20) and pneumococcal polysaccharide (PPSV23), are used to protect against pneumococcal disease. They offer substantial but not complete protection against various pneumococcal bacteria types (20).

The CDC recommends pneumococcal vaccines, especially for individuals at increased risk. All children under 5 years of age should receive PCV13 or PCV15. Children aged 5 to 18 years with certain underlying medical conditions—such as chronic heart, lung, or liver disease; diabetes; immunocompromising conditions; functional or anatomic asplenia; or alcoholism—should also receive PCV13 or PCV15, and those aged 2 to 18 with high-risk conditions should additionally receive PPSV23. A single supplemental dose of PCV13 is recommended for children aged 14 to 59 months who previously completed a PCV7 schedule. For children up to 71 months old with qualifying medical conditions, PCV13 or PCV15 should be given even if they previously received PPSV23. A minimum interval of 8 weeks is advised before administering another pneumococcal vaccine dose after the last PCV7 or PPSV23 dose. Both PCV and PPSV23 vaccines are safe, well tolerated, and effective, and they may be co-administered with other routine vaccines (04; 20).

Adults aged 65 or those 19 to 64 with certain medical conditions should receive either PCV20 alone or PCV15 followed by PPSV23. Those previously vaccinated with PCV13 or PCV7 should consult their doctor to complete the series. Adults who received PCV13 and PPSV23 at the age of 65 may consider PCV20 after discussing with their healthcare provider (20).

The CDC recommends PCV13 or PCV15 for all children under 5 years old and for those aged 5 to 18 years old with certain medical conditions, with PPSV23 added for high-risk individuals aged 2 to 18 years. A supplemental PCV13 dose is advised for children aged 14 to 59 months who previously completed a PCV7 series. High-risk children up to 71 months old should receive PCV13 or PCV15 even if they had PPSV23. An interval of at least 8 weeks is required between PCV and PPSV23. For adults aged 65 or those aged 19 to 64 with specific risk factors, either a single dose of PCV20 or a combination of PCV15 followed by PPSV23 is recommended. Those who received PCV13 but not all PPSV23 doses may get PCV20 or the remaining PPSV23. Adults who previously received PPSV23 alone should receive either PCV15 or PCV20. Both vaccine types are safe, effective, and can be given with other vaccines (20).

Those who began their vaccination series with the earlier 13-valent vaccine (PCV13) but haven’t received all recommended PPSV23 doses can opt for a single dose of PCV20 or one or more doses of PPSV23. For those who have received PPSV23 but not PCV, the new CDC guidance recommends either PCV15 or PCV20.

Following the introduction of PCV10 and PCV13, pneumococcal meningitis incidence significantly declined across all age groups globally. Six years post-vaccine rollout, reductions ranged from 48% to 74% in children under 5, 35% to 62% in those aged 5 to 17, and up to 36% in adults. High vaccine-type effectiveness (up to 100%) was observed. Importantly, serotype replacement by non-PCV13 types was minimal, suggesting lower replacement in meningitis than in overall invasive pneumococcal disease (107).

Differential diagnosis

Confusing conditions

The history and examination data obtained from any given case of acute bacterial meningitis can be quite variable. Some findings are typically present, whereas others may be absent. Additionally, the signs and symptoms frequently seen with acute bacterial meningitis, including fever, behavioral or personality changes, and mental status changes can be nonspecific and suggest other diagnoses, including systemic infection or sepsis, viral encephalitis or meningitis, fungal or tuberculous meningitis, trauma or closed head injury, multiple metabolic abnormalities (hypoglycemia, ketoacidosis, electrolyte imbalance, uremia, toxic exposure), seizure, and brain tumor. Even meningismus does not exclude alternative diagnoses such as subarachnoid hemorrhage, intracranial hemorrhage, and epidural abscess. To reduce the risk of morbidity and mortality from missed diagnoses, clinicians should maintain a high index of suspicion for acute bacterial meningitis and prioritize early initiation of treatment, even if the diagnosis is uncertain (07).

Streptococcus pneumoniae and Neisseria meningitidis are the most common etiologic agents of bacterial meningitis after 1 year of age. Due to passive transfer of maternal antibodies, neonates do not typically develop pneumococcal or meningococcal meningitis (71).

In patients over 50 years of age, the most common causes of bacterial meningitis include S pneumoniae, Listeria monocytogenes, and gram-negative bacilli (82; 54). H influenzae is included in the gram-negative group, along with E coli, Enterobacter, and Pseudomonas. S pneumoniae meningitis is more likely in association with pneumonia, Pseudomonas in association with chronic lung disease, E coli, or Enterobacter in the setting of urinary tract infection, and S pneumoniae or H influenzae in the setting of sinusitis, otitis media, head trauma, or a neurosurgical procedure. S pneumoniae and nontypeable H influenzae are also common etiological agents of recurrent meningitis in the setting of CSF leak (51; 01). One study provides good evidence that surgical repair of CSF leaks effectively prevents recurrent bacterial meningitis (92). Listeria monocytogenes can also be seen, especially in the immunosuppressed elderly, and Staphylococcus aureus is seen with dural disruption.

Management

When bacterial meningitis is suspected, emergent antibiotic treatment must be initiated without waiting for speciation (07). In persons older than the neonatal period, empiric treatment is directed primarily against S pneumoniae and N meningitidis. Current recommendations for treatment of community-acquired meningitis for ages 3 months to 50 years is vancomycin 15 mg/kg IV every 8 to 12 hours and up to 2 g/day (maintain serum trough concentration of 15 to 20 ug/ml) plus ceftriaxone 50 to 100 mg/kg IV every 12 hours (maximum 2 g IV every 12 hours). Because cefotaxime is no longer available in the United States, ceftriaxone is the preferred third-generation cephalosporin. For patients over 50 years old, addition of ampicillin 2 g IV every 4 hours is recommended (98; 64; 100).

In adults, dexamethasone should ideally be added to empirical therapy before or at the same time as the first antibiotic dose, and it should be continued for 4 days in those with proven pneumococcal meningitis (108). The dose is 0.15 mg/kg every 6 hours (28; 98; 101). The European Society of Clinical Microbiology and Infectious Diseases guidelines suggest that corticosteroids can still be started up to 4 hours after commencement of antibiotic treatment (100). The UK guidelines recommend that for adults, dexamethasone can be given up to 12 hours after antibiotics are started (64). There has been some concern that dexamethasone could decrease the penetration of vancomycin into the CSF. However, a study demonstrated that appropriate levels of vancomycin are reached in the CSF of patients with pneumococcal meningitis receiving dexamethasone as long as proper serum levels of vancomycin are maintained (84).

A 31-year retrospective study (1977 to 2018) on 363 cases of pneumococcal meningitis revealed that a low-dose dexamethasone protocol (12 mg dexamethasone followed by 4 mg/6 h for 48 h, started before or with the first antibiotic dose), combined with mannitol and phenytoin, significantly reduced mortality. Patients treated with dexamethasone had lower overall mortality (11.6% vs. 35%), early mortality (5.8% vs. 24%), and neurologic mortality (7.4% vs. 23%) compared to those without dexamethasone, highlighting its potential benefit in improving outcomes (13).

In a large French multicenter study of 1231 children with confirmed pneumococcal meningitis, early adjunctive dexamethasone therapy (within 12 hours of antibiotics) was associated with a significantly reduced 30-day mortality. Death occurred in 6% of the dexamethasone group versus 12% without dexamethasone. After adjusting for baseline severity using inverse probability treatment weighting, dexamethasone was linked to a 61% reduction in the odds of death (odds ratio: 0.39, 95% CI: 0.23–0.65). Sensitivity analyses confirmed the robustness of the findings, supporting early dexamethasone use to lower mortality in pediatric pneumococcal meningitis (38).

Current recommendations advocate for the immediate admission of pneumococcal meningitis patients to ICUs. A study of 4052 adults in France with pneumococcal meningitis and sepsis, conducted between 2011 and 2020, compared direct ICU admission with secondary ICU admission. Findings revealed that direct ICU admission significantly reduced mortality, even after adjusting for disease severity and other factors, preventing one death for every 11 patients directly admitted to the ICU (96).

In addition to medication therapies, it is imperative that appropriate supportive care be instituted. Advancements in intensive care techniques offer significant benefit for patients with bacterial meningitis, including S pneumoniae meningitis.

Outcomes

Pneumococcal meningitis has always been associated with a high possibility of mortality and morbidity in adults. Authors from the Netherlands analyzed data between October 1998 and April 2002 and between January 2006 and July 2018. The outcome of pneumococcal meningitis in adults was better in the latter era of administration of conjugate vaccines and adjunctive dexamethasone compared to the former era, when these two interventions were used less. Nonetheless, in a cohort of 1783 patients (1816 pneumococcal meningitis episodes), there were 363 episodes of in-hospital death (20%). Unfavorable outcomes were recorded in 772 episodes (43%). Delayed cerebral venous thrombosis occurred in 29 patients (2%), and more half of these died (53). Neurofunctional disability in adults is frequent 1 year after community-acquired bacterial meningitis, particularly following pneumococcal meningitis. In a cohort of 281 patients at 12 months, 84 (30%) patients had neuro-functional disability and six patients died. Dexamethasone did not impact the likelihood of neurofunctional disability (02).

The cerebrospinal fluid (CSF) bacterial load has been identified as a key indicator of worse outcomes in adults with pneumococcal meningitis. A study involving 152 patients revealed a median CSF bacterial load of 1.6 × 10⁴ DNA copies/mL. Higher bacterial loads were linked to severe complications such as circulatory shock and cerebrovascular issues, along with increased risk of unfavorable outcomes (OR: 2.8) and mortality (OR: 3.1) (21).

A pediatric observational study analyzed 505 cases of Streptococcus pneumoniae meningitis across three continents (63). Compared to other causes, this type of meningitis had double the mortality rate (33%) and triple the rate of poor outcomes (15%). Key predictors of poor outcomes included a Glasgow Coma Score below 13, age under 1 year, seizures, and prior parenteral antibiotic use. Outcomes were particularly severe in Angola.

References

01: Adriani KS, van de Beek D, Brouwer MC, Spanjaard L, de Gans J. Community-acquired recurrent bacterial meningitis in adults. Clin Infect Dis 2007;45(5):e46-51. PMID 17682979
02: Akroum S, Tubiana S, de Broucker T, et al. Long-term neuro-functional disability in adult patients with community-acquired bacterial meningitis. Infection 2022;50(5):1363-72. PMID 35657529
03: Albrich WC, Baughman W, Schmotzer B, Farley MM. Changing characteristics of invasive pneumococcal disease in Metropolitan Atlanta, Georgia, after introduction of a 7-valent pneumococcal conjugate vaccine. Clin Infect Dis 2007;44(12):1569-76. PMID 17516400
04: American Academy of Pediatrics. Pneumococcal infections. In: Pickering LK, editor. Red Book: 2006 Report of the Committee on Infectious Diseases, 27th edition. Elk Grove Village: American Academy of Pediatrics, 2006:525-37.
05: American College of Obstetricians and Gynecologists. Maternal immunization practice advisory October 2022. Accessed September 2023. Available at: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2022/10/maternal-immunization. 2022.
06: Artiaga A, Herman F, Arquizan C, et al. Cerebral vasculitis as a complication of pneumococcal meningitis: a cohort study. Infect Dis Now 2023;53(8):104772. PMID 37619963
07: Auburtin M, Wolff M, Charpentier J, et al. Detrimental role of delayed antibiotic administration and penicillin-nonsusceptible strains in adult intensive care unit patients with pneumococcal meningitis: the PNEUMOREA prospective multicenter study. Crit Care Med 2006;34:2758-65. PMID 16915106
08: Beadsworth MB, Wooton D, Chenzbraun A, Beeching NJ. Austrian’s syndrome: The first described case of pneumococcal meningitis pneumonia and endocarditis in an injecting drug user. Eur J Intern Med 2007;18:605-6. PMID 18054715
09: Boix-Palop L, Fernández T, Pelegrín I, et al. Delayed cerebral vasculopathy in pneumococcal meningitis: epidemiology and clinical outcome. A cohort study. Int J Infect Dis 2020;97:283-9. PMID 32531430
10: Brandt CT, Holm D, Liptrot M, et al. Impact of bacteremia on the pathogenesis of experimental pneumococcal meningitis. J Infect Dis 2008;197(2):235-44. PMID 18173365
11: Breiman RF, Spika JS, Navarro VJ, Darden PM, Darby CP. Pneumococcal bacteremia in Charleston County, South Carolina: a decade later. Arch Intern Med 1990;150:1401-5. PMID 2369239
12: Brueggemann AB, Jansen van Rensburg MJ, Shaw D, et al. Changes in the incidence of invasive disease due to Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis during the COVID-19 pandemic in 26 countries and territories in the Invasive Respiratory Infection Surveillance Initiative: a prospective analysis of surveillance data. Lancet Digit Health 2021;3(6):e360-70. PMID 34045002
13: Cabellos C, Guillem L, Pelegrin I, et al. A 30-year perspective of low-dose dexamethasone, a single dose of mannitol and antiseizures prophylaxis on the prognosis of pneumococcal meningitis. Infect Dis (Lond) 2024;56(11):974-82. PMID 38922314
14: Centers for Disease Control and Prevention. Pneumococcal vaccination: summary of who and when to vaccinate. Accessed June 2021a.
15: Centers for Disease Control and Prevention. Pneumococcal vaccine recommendations. Accessed June 2021b.
16: Centers for Disease Control and Prevention. Invasive Pneumococcal Disease (IPD) (Streptococcus pneumoniae) 2017 Case Definition. CSTE Position Statement(s), 16-ID-08. Available at: https://wwwn.cdc.gov/nndss/conditions/invasive-pneumococcal-disease/case-definition/2017/. Accessed November 2017.
17: Centers for Disease Control and Prevention. Guidelines for vaccinating pregnant women. Available at: https://www.cdc.gov/vaccines/pregnancy/hcp-toolkit/guidelines.html#ppsv23. Accessed May 2019.
18: Centers for Disease Control and Prevention. Pneumococcal vaccination. Available at: https://www.cdc.gov/pneumococcal/vaccines/index.html. Accessed September 2023.
19: Centers for Disease Control and Prevention. Pneumococcal disease: risk factors. Available at: https://www.cdc.gov/pneumococcal/about/risk-transmission.html. Accessed July 2025a.
20: Centers for Disease Control and Prevention. Pneumococcal vaccination: summary of who and when to vaccinate. Available at: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html. Accessed July 2025b.
21: Chekrouni N, van Soest TM, da Cruz Campos AC, Brouwer MC, van de Beek D. Bacterial load in cerebrospinal fluid predicts unfavourable outcome in pneumococcal meningitis: a prospective nationwide cohort study. Clin Microbiol Infect 2024;30(6):772-8. PMID 38479702
22: Corcoran M, Vickers I, Mereckiene J, et al. The epidemiology of invasive pneumococcal disease in older adults in the post-PCV era. Has there been a herd effect? Epidemiol Infect 2017;145(11):2390-9. PMID 28712384
23: Costerus JM, Brouwer MC, Sprengers MES, Roosendaal SD, van der Ende A, van de Beek D. Cranial computed tomography, lumbar puncture, and clinical deterioration in bacterial meningitis: a nationwide cohort study. Clin Infect Dis 2018;67(6):920-6. PMID 29522090
24: Cremers AJH, Mobegi FM, van der Gaast-de Jongh C, et al. The contribution of genetic variation of Streptococcus pneumoniae to the clinical manifestation of invasive pneumococcal disease. Clin Infect Dis 2019;68(1):61-9. PMID 29788414
25: Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics 2010;126(5):952-60. PMID 20974781
26: Dao TH, Rosch JW. JMM profile: Streptococcus pneumoniae: sugar-coated captain of the men of death. J Med Microbiol 2021;70(11):001446. PMID 34779760
27: Davidson M, Parkinson AJ, Bulkow LR, Fitzgerald MA, Peters HV, Parks DJ. The epidemiology of invasive pneumococcal disease in Alaska, 1986-1990: ethnic differences and opportunities for prevention. J Infect Dis 1994;170:368-76. PMID 8035023
28: de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002;347:1549-56. PMID 12432041
29: Deliran SS, Engelen-Lee JY, Brouwer MC, van de Beek D. Cerebral venous thrombosis in pneumococcal meningitis: an autopsy study. Clin Neuropathol 2021;40(3):126-33. PMID 33433314
30: Department of Health, Victoria. Invasive pneumococcal disease. Available at: https://www.health.vic.gov.au/infectious-diseases/invasive-pneumococcal-disease. Accessed 2025.
31: Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance. Pediatr Infect Dis J 1999;18:1-9. PMID 9951971
32: Eavey RD, Gao Y, Schuknecht HF, Pineda MG. Otologic features of bacterial meningitis of childhood. J Pediatr 1985;136:2025-9. PMID 3973777
33: Engelen-Lee JY, Brouwer MC, Aronica E, van de Beek D. Delayed cerebral thrombosis complicating pneumococcal meningitis: an autopsy study. Ann Intensive Care 2018;8(1):20. PMID 29427117
34: Engelen-Lee JY, Brouwer MC, Aronica E, van de Beek D. Pneumococcal meningitis: clinical-pathological correlations (MeninGene-Path). Acta Neuropathol Commun 2016;4:26. PMID 27001057
35: Forestier E, Sordet C, Solal JC, et al. Bone and joint infection due to Streptococcus pneumoniae in two immunocompetent adults. Joint Bone Spine 2006;73:325-8. PMID 16495104
36: GBD 2019 Meningitis Antimicrobial Resistance Collaborators. Global, regional, and national burden of meningitis and its aetiologies, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol 2023;22(8):685-711. PMID 37479374
37: Geiseler PJ, Nelson KE, Levin S, Reddi KT, Moses VK. Community acquired purulent meningitis: a review of 1316 cases during the antibiotic era, 1954-1976. Rev Infect Dis 1980;2:725-45. PMID 6763303
38: Giolito A, Levy C, Varon E, et al. Adjunctive dexamethasone and 30-day all-cause death after hospital admission in paediatric pneumococcal meningitis: a propensity score analysis. Lancet Child Adolesc Health 2025;9(4):255-61. PMID 40113367
39: Godeau B, Bachir D, Schaeffer A, et al. Severe pneumococcal sepsis and meningitis in human immunodeficiency virus infected adults with sickle cell disease. Clin Infect Dis 1992;15:327-9. PMID 1520768
40: Grigoriadis E, Gold WL. Pyogenic brain abscess caused by Streptococcus pneumoniae: Case report and review. Clin Infect Dis 1997;25:1108-12. PMID 9402366
41: Gwaltney JM, Scheld WM, Sande MA, Sydnor A. The microbial etiology and antimicrobial therapy of adults with acute community acquired sinusitis: a fifteen year experience at the University of Virginia and review of other selected studies. J Allergy Clin Immunol 1992;90:457-62. PMID 1527337
42: Hasbun R. Progress and challenges in bacterial meningitis: a review. JAMA 2022;328(21):2147-54. PMID 36472590
43: Hénaff F, Levy C, Cohen R, et al. Risk factors in children older than 5 years with pneumococcal meningitis: data from a National Network. Pediatr Infect Dis J 2017;36(5):457-61. PMID 28403047
44: Hoffmann O, Mahrhofer C, Rueter N, et al. Pneumococcal cell wall induced meningitis impairs adult hippocampal neurogenesis. Infect Immun 2007;75(9):4289-97. PMID 17591796
45: Hoge CW, Reichler MR, Dominguez EA, et al. An epidemic of pneumococcal disease in an overcrowded, inadequately ventilated jail. N Engl J Med 1994;331:643-8. PMID 8052273
46: Hoogman M, van de Beek D, Weisfelt M, de Gans J, Schmand B. Cognitive outcome in adults after bacterial meningitis. J Neurol Neurosurg Psychiatry 2007;78(10):1092-6. PMID 17353256
47: Hupp S, Förtsch C, Graber F, Mitchell TJ, Iliev AI. Pneumolysin boosts the neuroinflammatory response to Streptococcus pneumoniae through enhanced endocytosis. Nat Commun 2022;13(1):5032. PMID 36028511
48: Jacobs DM, Yung F, Hart E, Nguyen MNH, Shaver A. Trends in pneumococcal meningitis hospitalizations following the introduction of the 13-valent pneumococcal conjugate vaccine in the United States. Vaccine 2017;35(45):6160-5. PMID 28951086
49: Juanatey CG, Testa A, Mayo J, Gay MAG. Austrian syndrome: report of two new cases and literature review. Int J Cardiol 2006;108:273-5. PMID 16139379
50: King BA, Richmond P. Pneumococcal meningitis in Western Australian children: epidemiology, microbiology, and outcome. J Paediatr Child Health 2004;40:611-5. PMID 15469529
51: Kline MW. Review of recurrent bacterial meningitis. Pediatr Infect Dis J 1989;8:630-4. PMID 2677957
52: Kloek AT, Brouwer MC, Schmand B, Tanck MWT, van de Beek D. Long-term neurologic and cognitive outcome and quality of life in adults after pneumococcal meningitis. Clin Microbiol Infect 2020;26(10):1361-7. PMID 32006689
53: Koelman DLH, Brouwer MC, Ter Horst L, van der Ende A, van de Beek D. Pneumococcal meningitis in adults: a prospective nationwide cohort study over a 20-year period. Clin Infect Dis 2022;74(4):657-67. PMID 34036322
54: Koelman DLH, van Kassel MN, Bijlsma MW, Brouwer MC, van de Beek D, van der Ende A. Changing epidemiology of bacterial meningitis since introduction of conjugate vaccines: three decades of national meningitis surveillance in The Netherlands. Clin Infect Dis 2021;73(5):e1099-107. PMID 33247582
55: Kutz JW, Simon LM, Chennupati SK, Giannoni CM, Manolidis S. Clinical predictors for hearing loss in children with bacterial meningitis. Arch Otolaryngol Head Neck Surg 2006;132(9):941-5. PMID 16982970
56: Landrum LM, Hawkins A, Goodman JR. Pneumococcal meningitis during pregnancy: a case report and review of the literature. Infect Dis Obstet Gynecol 2007;2007:63624. PMID 17485820
57: Legouy C, Cornic R, Razazi K, et al. Intracranial complications in adult patients with severe pneumococcal meningitis: a retrospective multicenter cohort study. Ann Intensive Care 2024;14(1):182. PMID 39699714
58: Li L, Shui QX, Liang K, Ren H. Brain derived neurotrophic factor rescues neurons from bacterial meningitis. Pediatr Neurol 2007;36(5):324-9. PMID 17509465
59: Liechti FD, Bijlsma MW, Brouwer MC, van de Beek D. Effect of the COVID-19 pandemic on clinical characteristics and outcomes of adult pneumococcal meningitis patients - a Dutch prospective nationwide cohort study. Infection 2024;52(5):1657-62. PMID 38831205
60: Luzzati R, Pinamonti B, Giacomazzi D, Sinagra G, Zingone B. Aortic-right atrium fistula complicating Austrian Syndrome: a case report and literature review. Infez Med 2007;15(2):124-8. PMID 17599001
61: Manoharan A, Manchanda V, Balasubramanian S, et al. Invasive pneumococcal disease in children aged younger than 5 years in India: a surveillance study. Lancet Infect Dis 2017;17(3):305-12. PMID 27956163
62: Marriott HM, Dockrell DH. Streptococcus pneumoniae: the role of apoptosis in host defense and pathogenesis. Int J Biochem Cell Biol 2006;38(11):1848-54. PMID 16844403
63: Mbakwe PL, Roine I, Cruzeiro ML, Kallio M, Peltola H, Pelkonen T. Clinical picture and risk factors for poor outcome in Streptococcus pneumoniae meningitis of childhood on three continents. Pediatr Infect Dis J 2024;43(5):415-9. PMID 38359336
64: McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect 2016;72(4):405-38. PMID 26845731
65: McIntyre PB, Macintyre CR, Gilmour R, Wang H. A population based study of the impact of corticosteroid therapy and delayed diagnosis on the outcome of childhood pneumococcal meningitis. Arch Dis Child 2005;90:391-6. PMID 15781931
66: Mercat A, Nguyen J, Dautzenberg B. An outbreak of pneumococcal pneumonia in two men’s shelters. Chest 1991;99:147-51. PMID 1984946
67: Meroc E, Fletcher MA, Hanquet G, et al. Systematic literature review of the epidemiological characteristics of pneumococcal disease caused by the additional serotypes covered by the 20-valent pneumococcal conjugate vaccine. Microorganisms 2023;11(7):1816. PMID 37512988
68: Musher DM. Streptococcus pneumoniae. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. Philadelphia: Churchill Livingstone, 2000:2128-44.
69: Nuorti JP, Butler JC, Crutcher JM, et al. An outbreak of multidrug resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents. N Engl J Med 1998;338:1861-8. PMID 9637804
70: Oligbu G, Collins S, Djennad A, et al. Effect of pneumococcal conjugate vaccines on pneumococcal meningitis, England and Wales, July 1, 2000-June 30, 2016. Emerg Infect Dis 2019;25(9):1708-18. PMID 31441745
71: Oordt-Speets AM, Bolijn R, van Hoorn RC, Bhavsar A, Kyaw MH. Global etiology of bacterial meningitis: a systematic review and meta-analysis. PLoS One 2018;13(6):e0198772. PMID 29889859
72: Ort S, Ryan RL, Barden G, D’Esopo N. Pneumococcal pneumonia in hospitalized patients: clinical and radiological presentations. JAMA 1983;249:214-8. PMID 6848806
73: Ostergaard C, Hoiby N, Konradsen HB, Samuelsson S. Prehospital diagnostic and therapeutic management of otogenic Streptococcus pneumoniae meningitis. Scand J Infect Dis 2006;38:172-80. PMID 16507498
74: Ostergaard C, Konradsen HB, Samuelsson S. Clinical presentation and prognostic factors of Streptoccocus pneumoniae meningitis according to the focus of infection. BMC Infect Dis 2005;5:93. PMID 16253143
75: Papadopoulos MC, Verkman AS. Aquaporin-4 gene disruption in mice reduces brain swelling and mortality in pneumococcal meningitis. J Biol Chem 2005;280:13906-12. PMID 15695511
76: Pedersen M, Brandt CT, Knudsen GM, et al. The effect of S. pneumoniae bacteremia on cerebral blood flow autoregulation in rats. J Cereb Blood Flow Metab 2008;28(1):126-34. PMID 17565362
77: Perny M, Solyga M, Grandgirard D, Roccio M, Leib SL, Senn P. Streptococcus pneumoniae-induced ototoxicity in organ of Corti explant cultures. Hear Res 2017;350:100-9. PMID 28460251
78: Pikis A, Kavaliotis J, Tsikoulas J, Andrianopoulos P, Venzon D, Manios S. Long-term sequelae of pneumococcal meningitis in children. Clin Pediatr (Phila) 1996;35:72-8. PMID 8775479
79: Prasad N, Kobayashi M, Collins JP, et al. The epidemiology of bacterial meningitis in the United States during 2008-2023: an analysis of active, laboratory, population-based, multistate surveillance data. Lancet Reg Health Am 2025;47:101120. PMID 40486989
80: Quiambao BP, Nohynek HM, Kayhty H, et al. Immunogenicity and reactogenicity of 23-valent pneumococcal polysaccharide vaccine among pregnant Filipino women and placental transfer of antibodies. Vaccine 2007;25(22):4470-7. PMID 17442467
81: Ranzenigo M, van Soest TM, Hensen EF, et al. Otitis in patients with community-acquired bacterial meningitis: a nationwide prospective cohort study. Clin Infect Dis 2024;79(2):329-35. PMID 38655694
82: Rasmussen HH, Sorensen HT, Moller-Petersen J, Mortensen FV, Nielsen B. Bacterial meningitis in elderly patients: clinical picture and course. Age Ageing 1992;21:216-20. PMID 1615786
83: Raz R, Elhanan G, Shimoni Z, et al. Pneumococcal bacteremia in hospitalized Israeli adults: epidemiology and resistance to penicillin. Clin Infect Dis 1997;24:1164-8. PMID 9195076
84: Ricard JD, Wolff M, Lacherade JC, et al. Levels of vancomycin in cerebrospinal fluid of adult patients receiving adjunctive corticosteroids to treat pneumococcal meningitis: a prospective multicenter observational study. Clin Infect Dis 2007;449(2):250-5. PMID 17173226
85: Rupprecht TA, Angele B, Klein M, et al. Complement C1q and C3 are critical for the innate immune response to Streptococcus pneumoniae in the central nervous system. J Immunol 2007;178:1861-9. PMID 17237437
86: Sáez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet 2003;361(9375):2139-48. PMID 12826449
87: Sandgren A, Albiger B, Orihuela CJ, Tuomanen E, Normark S, Normark BH. Virulence in mice of pneumococcal clonal types with known invasive disease potential in humans. J Infect Dis 2005;192:791-800. PMID 16088828
88: Schwartz LE, Brown RB. Purulent otitis media in adults. Arch Intern Med 1992;152:2301-4. PMID 1444690
89: Sellner J, Leib SL. In bacterial meningitis cortical brain damage is associated with changes in parenchymal MMP9/TIMP1 ratio and increased collagen type IV degradation. Neurobiol Dis 2006;21:647-56. PMID 16257222
90: Siedler A, Reinert RR, Toschke M, Al-Lahham A, von Kries R. Regional differences in epidemiology of invasive pneumococcal disease in toddlers in Germany. Pediatr Infect Dis J 2005;24:1114-5. PMID 16371880
91: Singhi P, Bansal A, Geeta P, Singhi S. Predictors of long term neurological outcome in bacterial meningitis. Indian J Pediatr 2007;74(4):369-74. PMID 17476082
92: Sprekelsen MB, Alobid I, Mullol J, Trobat F, Barberan MT. Closure of cerebrospinal fluid leaks prevents ascending bacterial meningitis. Rhinology 2005;43:277-81. PMID 16405272
93: Subbarao S, Ribeiro S, Campbell H, Okike I, Ramsay ME, Ladhani SN. Trends in laboratory-confirmed bacterial meningitis (2012-2019): national observational study, England. Lancet Reg Health Eur 2023;32:100692. PMID 37538400
94: Subramanian K, Henriques-Normark B, Normark S. Emerging concepts in the pathogenesis of the Streptococcus pneumoniae: from nasopharyngeal colonizer to intracellular pathogen. Cell Microbiol 2019;21(11):e13077. PMID 31251447
95: Tauber SC, Stadelmann C, Spreer A, Bruck W, Nau R, Gerber J. Increased expression of BDNF and proliferation of dentate granule cells after bacterial meningitis. J Neuropathol Exp Neurol 2005;64:806-15. PMID 16141791
96: Thy M, Dupuis C, Mageau A, Mourvillier B, et al. Impact of direct ICU admission of pneumococcal meningitis in France: a retrospective analysis of a French medico-administrative (PMSI) database. Ann Intensive Care 2024;14(1):15. PMID 38279066
97: Torzillo PJ, Hanna JN, Morey F, Gratten M, Dixon J, Erlich J. Invasive pneumococcal disease in central Australia. Med J Aust 1995;162:182-6. PMID 7877538
98: Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004;39(9):1267-84. PMID 15494903
99: Turner DP, Weston VC, Ispahani P. Streptococcus pneumoniae spinal infection in Nottingham, United Kingdom: not a rare event. Clin Infect Dis 1999;28:873-81. PMID 10825053
100: van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect 2016;22 Suppl 3:S37-62. PMID 27062097
101: van de Beek D, de Gans J, McIntyre P, Prasad K. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis 2004;4:139-43. PMID 14998499
102: van Soest TM, Chekrouni N, van Sorge NM, Brouwer MC, van de Beek D. Bacterial meningitis presenting with a normal cerebrospinal fluid leukocyte count. J Infect 2022;84(5):615-20. PMID 35245581
103: Vieira AC, Gomes MC, Rolo Filho M, Eudes Filho J, Bello EJ, de Figueiredo RB. Streptococcus pneumoniae: a study of strains isolated from cerebrospinal fluid. J Pediatr (Rio J) 2007;83(1):71-8. PMID 17279283
104: Watanakunakorn C, Bailey TA. Adult bacteremic pneumococcal pneumonia in a community teaching hospital, 1992-1996: a detailed analysis of 108 cases. Arch Intern Med 1997;157:1965-71. PMID 9308508
105: Watson DA, Musher DM, Jacobson JW. A brief history of the pneumococcus in biomedical research: a panoply of discovery. Clin Infect Dis 1993;17:913-24. PMID 8286641
106: Weisfelt M, van de Beek D, Spanjaard L, Reitsma JB, de Gans J. Clinical features, complications, and outcome in adults with pneumococcal meningitis: a prospective case series. Lancet Neurol 2006;5:123-9. PMID 16426988
107: Yang Y, Knoll MD, Herbert C, et al. Global impact of 10- and 13-valent pneumococcal conjugate vaccines on pneumococcal meningitis in all ages: the PSERENADE project. J Infect 2025;90(3):106426. PMID 39864526
108: Young N, Thomas M. Meningitis in adults: diagnosis and management. Intern Med J 2018;48(11):1294-1307. PMID 30387309

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Ravindra Kumar Garg DM

Dr. Garg of King George's Medical University in Lucknow, India, has no relevant financial relationships to disclose.
See Profile

Editor

Christina M Marra MD

Dr. Marra of the University of Washington School of Medicine has no relevant financial relationships to disclose.
See Profile

Former Authors

Jeffrey A Rumbaugh MD

Patient Profile

Age range of presentation: 1 month to 65+ years
Sex preponderance: male:female, 1:1
Heredity: none
Population groups selectively affected: Eskimo, Native American Indian, Australian Aboriginal
Occupation groups selectively affected: child care center personnel

This is an article preview.
Start a Free Account
to access the full version.

Nearly 3,000 illustrations, including video clips of neurologic disorders.
Every article is reviewed by our esteemed Editorial Board for accuracy and currency.
Full spectrum of neurology in 1,200 comprehensive articles.
Listen to MedLink on the go with Audio versions of each article.

Questions or Comment?

MedLink, LLC

3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122

Toll Free (U.S. + Canada): 800-452-2400

US Number: +1-619-640-4660

Support: service@medlink.com

Editor: editor@medlink.com

ISSN: 2831-9125

Pneumococcal meningitis

Associated Disorders

Austrian syndrome
Bacterial meningitis
Endocarditis
Osteomyelitis
Otitis media
- Pleural empyema
- Pneumonia
- Septic arthritis
- Sinusitis

Differential Diagnosis

encephalitis
systemic infection
sepsis
viral encephalitis
viral meningitis
- fungal meningitis
- tuberculous meningitis
- trauma
- closed head injury
- child abuse
- hypoglycemia
- ketoacidosis
- electrolyte imbalance
- uremia
- toxic exposure
- seizure
- brain tumor
- subarachnoid hemorrhage
- intracranial hemorrhage
- epidural abscess
- Haemophilus influenzae
- Neisseria meningitidis
- Group B streptococci
- gram-negative enteric bacilli
- Escherichia coli
- Enterobacter
- Pseudomonas
- Listeria monocytogenes
- Staphylococcus aureus

Also Relevant

Gram-negative bacillary meningitis
Haemophilus influenzae meningitis
Headache associated with intracranial infection
Infective endocarditis
Meningococcal meningitis
- Neurologic complications of vaccination
- Recurrent meningitis

Pneumococcal meningitis …

Pneumococcal meningitis

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Outcomes

Special considerations

Pregnancy

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview.
Start a Free Account
to access the full version.

Questions or Comment?

Also in This Category

Genital herpes: neurologic complications

Cryptococcal meningitis

Tuberculosis of the CNS

Headache associated with HIV and AIDS

Whipple disease

Post-polio syndrome

Coccidioidomycosis: neurologic manifestations

Viral meningitis

Pneumococcal meningitis

Cite this article

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Outcomes

Special considerations

Pregnancy

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Genital herpes: neurologic complications

Cryptococcal meningitis

Tuberculosis of the CNS

Headache associated with HIV and AIDS

Whipple disease

Post-polio syndrome

Coccidioidomycosis: neurologic manifestations

Viral meningitis

This is an article preview.
Start a Free Account
to access the full version.