Bacterial meningitis continues as a major cause of morbidity and mortality among children throughout the world. McIntyre et al report on a six year experience in Australia with 122 cases of pneumococcal meningitis; 89% of cases occurred in children less than 5 years of age.¹ Fifteen (13%) children died and 23 (22%) suffered severe neurological outcomes including paresis, hydrocephalus with shunting, visual loss, and marked intellectual impairment. Only 55% recovered without any identified sequelae. How can we improve the outcome of pneumococcal meningitis?

Early antibiotic treatment appears appealing as a fundamental for improving outcome, yet not all cases treated early have a good outcome. The report of McIntyre et al shows once again that children presenting “in extremis” (shock, respiratory failure, etc) are frequently beyond the full benefits of intervention regardless of whether their course was one with rapid onset or more slowly progressive after a prodromal illness. However, the authors report that delay in admission to the hospital is likely to contribute to poor outcome. Yet, once at the hospital, the time to antibiotic administration (either 4–12 hours or later) was not associated with enhanced morbidity in survivors. These observations support the practice of complete evaluation including blood and cerebrospinal fluid (CSF) cultures, when not contraindicated, prior to initiation of therapy as there is no evidence that short delays resulting from transport and/or performance of a lumbar puncture or computed tomography (to rule out increased intracranial pressure) results in increased morbidity.

Lebel and McCracken reported excess morbidity among children whose cerebral spinal fluid culture remained positive for the causative pathogen 18 to 36 hours after …