BMC Public Health 2009, 9:300 http://www.biomedcentral.com/1471-2458/9/300 working in Italy in 2007 (Italian Pediatric Society secretar- iat: personal communication), and were all attending the Annual Congress of the Italian Pediatric Society. There- fore, our study population may be not representative of all Italian pediatricians/pediatric residents. Second, it is well known that self-reported behavior can be misleading since some participants might not complete the survey as carefully as they would provide medical care [19]. The fact that other two similar surveys conducted in the United States [7,8] and one observational study on children attending an emergency department in Spain [20] docu- mented results similar to ours further corroborate our findings. Finally, the attitude toward urine testing has been reported to vary among pediatricians, and a poten- tial limitation of our study is that results may have dif- fered if the child's age was younger or if the gender was specified [21]. Encouraging results of large epidemiological studies indi- cate substantial reduced risk of invasive pneumococcal infection in children vaccinated with PCV [22]. The effects of decreased rates of pneumococcal disease on routine clinical practice are potentially significant [23]. However, pneumococcal serotype replacement has been docu- mented [24], and, to date, evidence is lacking to modify algorithms for the management of the febrile child, con- sidering his/her PCV vaccination status. Conclusion Italian pediatricians may obtain less blood and urine tests and prescribe less empiric antibiotic treatments in well- appearing young febrile children if they have received PCV. However, until more data are available regarding the actual risk of bacterial infection in children vaccinated with PVC in developed countries, this approach should not be sanctioned. Competing interests The authors declare that they have no competing interests. Authors' contributions EC, LG, FB and EV initiated the study, the design, and the data collection. EC, EV and MdM performed the statistical analysis and were involved in the interpretation of the results. EC, LG, NP and Mdm wrote the manuscript. All authors read and approved the final manuscript. Additional material Additional file 1 Clinical scenario and questionnaire. Click here for file [http://www.biomedcentral.com/content/supplementary/1471- 2458-9-300-S1.doc] Acknowledgements The authors are grateful to Prof. Pasquale Di Pietro, President of The Italian Society of Pediatrics, for the permission to carry out the survey and to Bra- dley J. Crosby, MD, Wake Forest University School of Medicine, Winston- Salem, NC, USA, for revision of the English language. References 1. Antonyrajah B, Mukundan D: Fever without apparent source on clinical examination. CurrOpin Pediatr 2008, 20:96-102. 2. Baraff LJ: Management of fever without source in infants and children. Ann Emerg Med 2000, 36:602-14. 3. Pichichero ME, Casey JR: Emergence of a multiresistant sero- type 19A pneumococcal strain not included in the 7-valent conjugate vaccine as an otopathogen in children. JAMA 2007, 298:1772-8. 4. Hsu HE, Shutt KA, Beall BW, Bennett NM, Craig AS, Farley MM, Jor- gensen JH, Lexau CA, Petit S, Reingold A, Schaffner W, Thomas A, Whitney CG, Harrison LH: Effect of pneumococcal conjugate vaccine on pneumococcal meningitis. New Engl J Med 2009, 360:244-56. 5. Moore MR, Gertz RE, Woodbury RL, Barkocy-Gallagher GA, Schaff- ner W, Lexau C, Gershman K, Reingold A, Farley M, Harrison LH, Hadler JL, Bennet NM, Thomas AR, McGee L, Pilishvili T, Bruegge- mann AB, Whitney CG, Jorgensen JH, Beall B: Population snapshot of emergent Streptococcus pneumoniae serotype 19A in the United States, 2005. J Infect Dis 2008, 197:1016-22. 6. Hickes LA, Harrison LH, Flannery B, Hadler JL, Schaffner W, Craig AS, Jackson D, Thomas A, Beall B, Lynfield R, Reingold A, Farley MM, Whitney CG: Incidence of pneumococcal disease due to non- pneumococcal conjugate vaccine (PCV7) serotypes in the United States during the era of widespread PCV7 vaccina- tion, 1998–2004. J Infect Dis 2007, 196:1346-54. 7. Gabriel ME, Aiuto L, Kohn N, Barone SR: Management of febrile children in the conjugate pneumococcal vaccine era. Clin Pedi- atr 2004, 43:75-82. 8. Lee KC, Finkelstein JA, Miroshnik IL, Rusinak D, Santoli JM, Lett SM, Lieu TA: Pediatricians' self-reported clinical practices and adherence to national vaccination guidelines after the intro- duction of pneumococcal conjugate vaccine. Arch Pediatr Ado- lesc Med 2004, 158:695-701. 9. Esposito S, Bosis S, Pelucchi C, Begliatti E, Rognoni A, Bellasio M, Tel F, Consolo S, Principi N: Pediatrician knowledge and attitudes regarding human papillomavirus disease and its prevention. Vaccine 2007, 25:6437-46. 10. Wittler RR, Cain KK, Bass JW: A survey about management of febrile children without source by primary care physicians. Pediatr Infect Dis J 1998, 17:271-7. 11. Baraff LJ: Management of infants and children 3 to 36 months of age with fever without source. Pediatr Ann 1993, 22:497-8. 12. Ishimine P: Fever without source in children 0 to 36 months of age. Pediatr Clin North Am 2006, 53:167-94. 13. ACEP Clinical Policies Committee and the Clinical Policies Committee and the Clinical Policies Subcommittee on Pedi- atric Fever, Clinical policy for children younger than three years presenting to the emergency department with fever. Ann Emerg Med 2003, 42:530-45. 14. National Institute for Health and Clinical Excellence: Feverish ill- ness: assessment and initial management in children younger than 5 years. 2007 [http://www.nice.org.uk/CG047]. London: NICE Accessed May 10, 2008 15. Sur DK, Bukont EL: Evaluating fever of unidentifiable source in young children. Am Fam Physician 2007, 75:1805-11. 16. Davis MM, Ndiaye SM, Freed GL, Clark SJ: One-year uptake of pneumococcal conjugate vaccine: a national survey of family physicians and pediatricians. J Am Board Fam Pract 2003, 16:363-71. 17. Montagnani F, Fanetti A, Stolzuoli L, Croci L, Arena F, Zanchi A, Cellesi C: Pneumococcal disease in a paediatric population in a hospital of central Italy: a clinical and microbiological case series from 1992 to 2006. J Infect 2008, 56:179-84. 18. Rothrock SG, Green SM, Harper MB, et al.: Parenteral vs oral anti- biotics in the prevention of serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia: a meta-analysis. Acad Emerg Med 1998, 5:599-606. Page 6 of 7 (page number not for citation purposes)