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Critical Care Medicine www.ccmjournal.org e155 The authors reply: We appreciate the comments of Mitchell et al (1), regarding our observations of the association of adjunctive steroids and delayed cerebral injury (DCI) in adults with bacterial meningitis (2). We acknowledge that cerebral infarction is not a novel complication of bacterial meningitis but want to clarify that the association of DCI with adjunctive steroids is. Cerebral infarctions are seen in 14–25% of adult patients with acute bacterial meningitis with approximately two thirds of them occurring in the first 4 days of presentation (3, 4). Our study (2) is the first one done in the United States confirming the findings from the Dutch Meningitis cohort that DCI is a rare but devastating complication of bacterial meningitis. Furthermore, our study (2) is the first one showing a statistical association between the use of adjunctive steroids and DCI. Furthermore, our study (2) did not only focus in patients with pneumococcal meningitis but also found DCI in Staphylococcus aureus and Listeria monocytogenes. Mitchell et al (1) raise an important question: is this association due to the prothrombotic effects of steroids and is this risk is dose-dependent? This question is unknown as there are no randomized studies evaluating different dosing regimens of adjunctive steroids in bacterial meningitis and most likely never will as doing such a study would be a huge undertaking. Dr. Hasbun received funding from Biofire, Biomeriaux, and Merck, and he received support for article research from Grant A Starr Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.