CNS INFLAMMATORY DISORDERS: INFECTIOUS DISEASES: Edited by Erich SchmutzhardAcute bacterial meningitisWall, Emma C.a,b; Chan, Jia Munb; Gil, Elizab; Heyderman, Robert S.b Author Information aFrancis Crick Institute bNIHR Mucosal Pathogens Research Unit, Department of Infection, Division of Infection and Immunity, University College London, London, UK Correspondence to Emma C. Wall, NE424, Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK. Tel: +44 203 7960000; e-mail: [email protected] This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0 Current Opinion in Neurology: June 2021 - Volume 34 - Issue 3 - p 386-395 doi: 10.1097/WCO.0000000000000934 Buy Metrics Abstract Purpose of review Community-acquired bacterial meningitis is a continually changing disease. This review summarises both dynamic epidemiology and emerging data on pathogenesis. Updated clinical guidelines are discussed, new agents undergoing clinical trials intended to reduce secondary brain damage are presented. Recent findings Conjugate vaccines are effective against serotype/serogroup-specific meningitis but vaccine escape variants are rising in prevalence. Meningitis occurs when bacteria evade mucosal and circulating immune responses and invade the brain: directly, or across the blood–brain barrier. Tissue damage is caused when host genetic susceptibility is exploited by bacterial virulence. The classical clinical triad of fever, neck stiffness and headache has poor diagnostic sensitivity, all guidelines reflect the necessity for a low index of suspicion and early Lumbar puncture. Unnecessary cranial imaging causes diagnostic delays. cerebrospinal fluid (CSF) culture and PCR are diagnostic, direct next-generation sequencing of CSF may revolutionise diagnostics. Administration of early antibiotics is essential to improve survival. Dexamethasone partially mitigates central nervous system inflammation in high-income settings. New agents in clinical trials include C5 inhibitors and daptomycin, data are expected in 2025. Summary Clinicians must remain vigilant for bacterial meningitis. Constantly changing epidemiology and emerging pathogenesis data are increasing the understanding of meningitis. Prospects for better treatments are forthcoming. Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.