We conducted a retrospective analysis of 55 community-acquired Streptococcus pneumoniae meningitis illnesses in Huntington, West Virginia, from 1978 to 1997. Fourteen (36.8%) of 38 adults and 2 (11.8%) of 17 children died. Serotypes 6, 23, 3, and 18 accounted for 20 (41.7%) of 48 strains available for serotyping. Of 40 strains available for antimicrobial susceptibility testing, 1 serotype 19 and 1 serotype 23 strain showed intermediate resistance and a second serotype 23 strain showed high resistance to penicillin; all three patients survived. The case-fatality rates among adults who received penicillin alone, gentamicin in combination, or vancomycin and cephalosporin together were 57.1%, 55.5%, and 60%, respectively, and among those who received chloramphenicol or a third-generation cephalosporin, they were 11.1% or nil, respectively. No child died who received chloramphenicol or vancomycin. Two (33%) of 6 children died who received a third-generation cephalosporin; both were critically ill when initially treated. No child and one adult had received pneumococcal vaccine prior to becoming ill.