BMC Public Health 2009, 9:300 http://www.biomedcentral.com/1471-2458/9/300 non-entity in the near future, and screening blood tests (e.g. complete blood cell count with differential, blood culture), and empiric antibiotic treatment will become unnecessary [2]. lish for publication. Responses were anonymous, but demographic (age, gender, graduation year) and profes- sional (primary care pediatrician, hospital pediatrician, or pediatric resident) information was requested. However, available data are insufficient to support modi- fications of current clinical practice guidelines. Also of concern, increasing rates of infections due to antimicro- bial resistant pneumococcal serotypes not-included into the heptavalent PCV have been reported [3-6] To the best of our knowledge two surveys previously investigated physicians' self-reported attitudes toward the management of young children presenting with a fever without a source, since the introduction of PCV [7,8]. Both the studies were conducted in the United States and found that pediatricians would order fewer complete blood cell counts, blood cultures, and urine tests, and would prescribe less antibiotics in the event that the child is vaccinated with PCV [7,8]. Thus the introduction of PCV seems to affect pediatricians' decision making in the United States. No similar study has been conducted in an European country. Therefore, we carried out a cross-sec- tional survey on a sample of Italian pediatricians regard- ing the management of a hypothetical well-appearing, young child presenting with a fever without a source, with relation to his/her anti-pneumococcal vaccination status. Methods Study population The sample included representatives from the two differ- ent categories of pediatricians operating in Italy (primary care pediatricians, and hospital pediatricians), as well as a group of post-graduate physicians, specializing in pediat- rics. All of the pediatricians and pediatric residents regis- tered at the Annual Congress of the Italian Society of Pediatrics held in Pisa, Italy, September 26–29, 2007, were considered eligible for enrollment. This Congress is usually attended by 20–25% of the Italian pediatricians and a similar proportion of pediatric residents [9]. Over- all, 1500 questionnaires were distributed. Questionnaire and its administration A self-administered, anonymous questionnaire was dis- tributed to all the physicians at the Congress registration desk. The questionnaire included an explanatory cover let- ter and was prepared by the authors on the basis of a sim- ilar clinical scenario presented to United States pediatricians in a previous study by Wittler and colleagues [10]. The questionnaire was previously pilot-tested on a convenient sample of primary care pediatricians, hospital pediatricians and pediatric residents in order to ensure clarity and ease of administration. The English version of the clinical scenario is shown in Additional File 1. The sur- vey was administered in Italian and translated into Eng- Participants were asked whether they would send the chil- dren home and follow-up ("wait-and see"), would obtain blood tests, or would treat them empirically with antibi- otic therapy. Subsequently, pediatricians were asked to mark on a checklist whether they would perform, erythro- cyte sedimentation rate, C reactive protein, blood culture, urine analysis or dipstick, urine culture, stool culture, group A β-haemolitic streptococcus rapid test, chest X-ray, abdomen ultrasound scan, or lumbar puncture or whether they would observe and re-evaluate the child later without performing laboratory studies. A blank space was provided in which to write in additional studies thought to be appropriate. A hypothetical blood test exam showing white blood cell count of 17.500/μL (with 45% segmented neutrophils, 15% band forms and 40% lym- phocytes) was provided. This scenario was similar to that one previously developed by Wittler and colleagues [10]. Participants were also asked whether, in such scenario, they would send children home and subsequently follow- up, treat them empirically with an antimicrobial or would admit them to hospital. They were also asked to specify which antibiotic they would use for empiric therapy. An additional question was exclusively directed to primary care pediatricians, addressing whether they usually use rapid tests in their offices. A final question explored the participants' general attitudes toward PCV recommenda- tion. The study was in compliance with the Helsinki Dec- laration and was approved by the Ethical committee of the Meyer Children Hospital, Florence, Italy. All the physi- cians gave their informed consent to fill out an anony- mous survey. Statistical methods Results were stratified by the participants' professional category. Differences in responses regarding the PCV vac- cination status evaluated by contingency table analysis with the χ2 or the Fisher's exact test, as appropriate. SPSS® software package ((SPSS 11.5; Chicago, IL) was used, and P < 0.05 was considered as statistically significant. Results Participants' characteristics Overall, 690 pediatricians or pediatric residents (46.0% of physicians registered to the Congress) returned the ques- tionnaire. Median age was 48.4 years (interquartile range [IQR]: 35.7–54.0), and 415 (60.06%) were females. Three hundred (46.48%) were primary care pediatricians; 251 (36.38%) were hospital pediatricians and 139 (20.14%) were pediatric residents. Page 2 of 7 (page number not for citation purposes)