Pneumococcal infections are common in Malawian adults. We set out to determine which factors influence in-hospital mortality and long-term survival among these patients. Features of history and examination, inpatient mortality and long-term survival were described among consecutively admitted QECH patients with S. pneumoniae in blood or CSF. 217 patients with pneumococcal disease were studied over an 18-month period. Among these, 158 of 167 consenting to testing (95%) were HIV positive. Inpatient mortality was 65% for pneumococcal meningitis (n=64), 20% for pneumococcaemic pneumonia (n=92) and 26% for patients with pneumococcaemia without localising signs (n=43). Lowered conscious level (OR 5.8, p