A global review finds growing antimicrobial resistance among the main bacteria causing meningitis—especially in low- and middle-income countries—raising concerns about the continued effectiveness of standard treatments and the urgent need for stronger surveillance.
Bacterial meningitis remains a life-threatening condition worldwide, with the highest burden falling on low-income and middle-income countries (LMICs). Despite its severity, data on antimicrobial resistance (AMR) patterns in meningitis-causing pathogens have been fragmented, limiting the ability of clinicians and policymakers to respond effectively. A new systematic review and meta-analysis sought to close this gap by estimating meningitis-specific resistance prevalence and trends for key antibiotics, both globally and across World Health Organization (WHO) regions.
The review analyzed peer-reviewed studies published between January 2010 and May 2024 that reported antimicrobial susceptibility testing results for microbiologically confirmed meningitis caused by Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae. Researchers screened more than 1,500 studies and ultimately included 88 reports, representing 16,441 clinical isolates from 37 countries across all WHO regions—predominantly LMICs. Using multilevel random-effects meta-analysis, the authors estimated resistance prevalence and trends for commonly used meningitis treatments, including benzylpenicillin, third-generation cephalosporins (3GCs), ciprofloxacin, and ampicillin.
Among S pneumoniae, the most frequently reported pathogen, resistance levels varied widely by region. Benzylpenicillin resistance ranged from about 15% to 58% across WHO regions, with a global estimate of 27%. Resistance to 3GCs was lower overall but still concerning, reaching more than 20% in some regions and nearly 9% globally. Notably, benzylpenicillin resistance in pneumococcal meningitis increased over time in LMICs, while both benzylpenicillin and 3GC resistance declined in high-income countries, highlighting widening global inequities.
What You Need to Know
Antimicrobial resistance in meningitis is rising globally, with the greatest increases seen in LMICs, especially for first-line treatments like benzylpenicillin.
Resistance patterns vary widely by pathogen and region, underscoring the need for locally informed treatment guidelines rather than one-size-fits-all approaches.
Strengthening national and regional AMR surveillance systems is critical to improve data quality, guide therapy, and protect patients from increasingly drug-resistant meningitis.
For N meningitidis, resistance was most pronounced in the African region. Globally, nearly one in four isolates showed resistance to benzylpenicillin, with evidence of increasing resistance over time. Resistance to 3GCs and ciprofloxacin remained lower overall but reached double-digit levels in some regions, raising alarms about future treatment options, particularly during outbreaks.
Data on H influenzae were more limited, reflecting gaps in surveillance and reporting. Even so, more than half of isolates were resistant to ampicillin globally, and over 8% showed resistance to 3GCs—concerning figures given the reliance on these drugs for empiric therapy in many settings.
Beyond resistance levels, the review highlighted substantial weaknesses in study quality and reporting. None of the included studies met all mandatory criteria of the Microbiology Investigation Criteria for Reporting Objectively (MICRO) checklist, with a median of four required items missing. These gaps further complicate efforts to generate reliable, comparable AMR data for meningitis.
Overall, the findings underscore a growing challenge: antimicrobial-resistant meningitis pathogens are becoming more common, particularly in regions with the least access to advanced diagnostics, second-line therapies, and robust surveillance systems. Without coordinated action, rising resistance threatens to erode decades of progress in meningitis treatment and prevention.
Reference
1.Lazarus G, Caddey B, Dean A, et al. Antimicrobial resistance in bacterial meningitis caused by Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae (2010-24): a systematic review and meta-analysis. Lancet Microbe. Published online January 27, 2026. doi:10.1016/j.lanmic.2025.101238
