BMC Public Health 2009, 9:300 http://www.biomedcentral.com/1471-2458/9/300 icant difference was observed among physician categories (P = 0.475). An additional analysis was performed, considering whether response pattern differs among participants who recommend PCV for all children and those who do not. The wait-and see option has been chosen by 169/229 (73.8%) pediatricians who do not recommend PVC rou- tinely vs. 327/461 (70.9%) pediatricians who recommend PCV routinely (p = 0.485) considering the not-vaccinated child, and by 147/221 (66.5%) pediatricians who do not recommend PVC routinely vs. 259/461 (56.2%) pediatri- cians who recommend PCV routinely considering the vac- cinated child (p = 0.013). Discussion Results of our survey indicate that pediatricians' self- reported management of the well-appearing young child with a fever without a source considerably change whether (s)he had received PCV or not. The majority (about 60%) of pediatricians/pediatric residents report to "wait-and see" if the child was not vaccinated with PCV, and this proportion significantly increased if the child had received PCV, reaching 76.0%. Parallel to this finding, physicians would choose to obtain blood tests and begin empiric antibiotic therapy less frequently in the vacci- nated than in the not-vaccinated child. Empiric antibiotic therapy would be started by about 3.0% of participants if the child had received PCV. The preferred antibiotic treat- ment for empiric therapy was largely amoxicillin or amox- icillin/clavulanic acid. In the event that the child showed white blood cell count of 17,500/μL (making the risk of bacterial infection higher), one third of participants still would "wait-and see" and send the unvaccinated child home with no therapy. This rate reaches about 45% if the child was vaccinated with PCV, with no significant differ- ence among results obtained by primary care or hospital pediatricians, or pediatric residents. A significantly lower proportion of participants would obtain erythrocyte sedi- mentation rate, C reactive protein, blood culture, and urine analysis/or dipstick if the child was vaccinated with PCV. Only two thirds of the our participants report to rec- ommend routinely PCV. Additionally, we documented that self-reported use of quick tests (including C reactive protein quick test, group A β-haemolitic streptococcus rapid test, and urine dipstick) is widespread among Italian primary care pediatricians. In general, our survey results show that management of the well-appearing young child with fever without source is heterogeneous among Italian pediatricians/pediatric residents. Similar data have been previously reported by Wittler and colleagues in 1998 [10], after the proposal of the U.S. guideline for the management of the febrile child [11]. Later, this guideline has been revisited [2]. Subse- quently, other algorithms about the management of the febrile child have been published, including some regard- ing the "wait-and see" approach [12-15]. This approach was the preferred option by our participants, who likely considered the low risk of bacterial infection in this hypo- thetical child. Nevertheless, the fact that one third of par- ticipants still chooses this approach when white blood cell count is 17,500/μL raises concern. Results similar to ours have been previously reported among United States pediatricians [7,8]. It is worth noting that an unintended effect of PVC widespread on the man- agement of the young children with a fever without a source may include reduced efforts to diagnose urinary tract infection, whose pathogenesis and incidence are not influenced by the child's anti-pneumococcal vaccination status. Possibly, physicians perceive that the PCV vacci- nated child is, in general, at minimal risk for all bacterial infections. Indeed, several types of bacterial infections should be ruled out, besides Streptococcus pneumoniae infection, including those due to Neisseria meningitidis, Escherichia coli, and Staphylococcus aureus [14]. The finding that only two-thirds of our participants report to recommend routinely PCV suggests that informative campaign is urgently needed in Italy. This is in strong con- trast with results from the United States, where one year after PCV was recommended, nearly all pediatricians had incorporated this vaccine [15,16]. The preferred antibiotic treatment for empiric therapy was oral amoxicillin. The low use of macrolides is justified in Italy, since bacterial resistance to this class of drugs is wide-spread, as well as in other European countries [17]. The choice of an oral antibiotic with respect to ceftriaxone is in contrast with current guidelines, recommending ceftriaxone or another third generation cephalosporin [14]. Pediatricians might have considered the results of studies showing equal efficacy of oral and parenteral anti- biotics in preventing severe bacterial infections in well- appearing children with Streptococcus pneumoniae occult bacteraemia [18]. Possibly, they considered the reduced discomfort from an oral course of antibiotics. However, it must be remembered that, according to the current guide- lines, in a child older than three months, presenting with a fever and suspected serious bacterial infection, antibiot- ics should cover Neisseria meningitidis, Streptococcus pneu- moniae, Escherichia coli, Staphylococcus aureus and Haemophilus influenzae type b. Thus, ceftriaxone or cefo- taxime should be considered as the first line therapy [14]. Our investigation has potential limitations. First, our results may not generalize to all pediatricians nationwide. Participans included in the study constituted approxi- mately 10% of all the about 7500 Italian pediatricians Page 5 of 7 (page number not for citation purposes)