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BACKGROUND Severe community-acquired pneumococcal meningitis is a medical emergency. The aim of the present investigation was to evaluate the epidemiology, management and outcomes of this condition. METHODS Retrospective, observational and multicenter cohort study. Sixteen Spanish intensive care units were included. Demographic, clinical and microbiological variables in critically ill adults with Streptococcus pneumoniae meningitis were evaluated. Clinical response was evaluated at 72h after antibiotic treatment initiation and meningitis complications, length of stay and 30-day mortality were also recorded. RESULTS In total, 255 patients were included. Cerebrospinal fluid (CSF) culture was positive in 89.7%; 25.7% were non-susceptible to penicillin, and 5.2% were non-susceptible to ceftriaxone or cefotaxime. The most frequent empiric antibiotic regimen was third-generation cephalosporin (47.5%) plus vancomycin (27.8%) or linezolid (12.9%). A steroid treatment regimen was administered to 88.6% of the patients. Clinical response was achieved in 65.8% of patients after 72 h of antibiotic treatment. Multivariate analysis identified two factors associated with early treatment failure: invasive mechanical ventilation (OR 12.66; 95% CI 1.90–84.55, p = 0.009) and septic shock (OR: 11.44; 95% CI 1.74–75.26, p = 0.011). The 30-day mortality rate was 13.7%. Only two factors were independently associated with 30-day mortality: Delay in start of antibiotic treatment (OR: 26.54; 95% CI 1.01–67.69, p = 0.049) and Sepsis related Organ Failure Assessment (SOFA) score (OR: 1.59; 95% CI 1.11–2.27, p = 0.011). Neurological complications appeared in 124 patients (48.63%). CONCLUSIONS Mortality rate in critically ill patients with pneumococcal meningitis is lower than previously reported. Delay in antibiotic treatment following admission is the only amendable factor associated with mortality.