No statistically significant mortality association was demonstrated for the CSF bacterial load or CSF white

cell count, HIV status, age or gender on model 1 (n = 102); seizures at any time in the illness, GCS or altered mental status and anaemia were associated with mortality ( Table 1). In model HDAC inhibitor review 2 (n = 62) IL8 and IL10 were marginal predictors of non-survival; IL8 p = 0.036, OR 1.00 (95% CI 1.00: 1.00) and IL10 p = 0.029, OR 1.00 (95% CI 1.00 : 1.00); of the clinical parameters, only altered mental status or GCS retained significance in this model ( Supplementary Table 1). We have previously shown that coma, seizures and anaemia predict poor outcome from bacterial meningitis in Malawi,5 but the causes of the excess mortality compared to patients in more well-resourced settings remain unclear. In this study, there was no difference

in the bacterial load and only marginal difference in the cytokine response between survivors and non-survivors despite lower CSF white cell counts in non-survivors. Our findings are markedly different to data in children with pneumococcal meningitis in Malawi and Europe, and adults with pneumococcal bacteraemia in Europe or meningococcal meningitis in the UK.6, 7, 8 and 14 No published data has quantified CSF pneumococcal load in adults learn more with meningitis in either setting. The lack of association between outcome and pneumococcal load, in contrast to these other studies was unexpected. HIV uninfected adults with pneumococcal meningitis in Europe have a 10 fold higher CSF WCC from than our patients, a CSF WCC of <1000 cells/mm3 has been shown to be significantly associated

with mortality in Europe.4 In our study, the median CSF WCC was substantially below this threshold, and low CSF WCCs were associated with poor outcome. We hypothesise that in adults with pneumococcal meningitis in Malawi, rapid bacterial growth occurs within the CSF with relatively little restriction by the host immune response, leading to high bacterial loads in both outcome groups. In addition, delays from symptom onset to admission in the community and to lumbar puncture within the hospital system may have resulted in the bacterial growth reaching the plateau, as opposed to the exponential growth phase in the CSF by the time of lumbar puncture, and hence any differences between outcome groups may have equalised by the time of examination. Time from symptom onset to lumbar puncture in the included studies was 3–5 days, compared to <48–72 h for most European studies.11, 12, 15, 16 and 17 Adults with pneumococcal meningitis in Malawi have different baseline characteristics compared to those studied in other settings outside of sub-Saharan Africa,4 and 5 and disease is caused disproportionately by serotype one.18 Data from studies of pneumococcal meningitis in this region may not be directly comparable to data from other regions.