Treatment of bacterial meningitis in children requires the choice of the optimal antimicrobial substance: besides the in vitro susceptibility also pharmacokinetic parameters (CSF penetration and elimination) have to be considered. A careful medical history and a few laboratory tests (gram-stain and antigen determination) provide a preliminary bacterial diagnosis within less than one hour. In addition to the identification of the causative organism also the determination of the number of colony forming units per milliliter CSF is of crucial importance. A rapid bacterial cell kill of high numbers of pneumococci, meningococci and streptococci group B overwhelms the CSF with endotoxins with rapidly increasing cerebral edema. Applying a slowly increasing dosage regimen proved effective in preventing this detrimental effects. Supportive therapy e.g. treatment of septic shock, disseminated intravascular coagulation, cerebral edema and anticonvulsive therapy is of paramount importance. Inadequate ADH secretion in the majority of patients requires a restricted fluid and electrolyte supplementation. By this combined therapeutic approach a remarkable low lethality rate and a low number of patients with late sequelae was seen.