Your point is well taken..! However, within the CI stated, the point estimate for the incidence of pneumococcal bacteremia in un-immunized infants could be as high as 4 fold greater than in infants that received at least one immunization. I was simply citing this article as a response to a comment in the thread that there is no evidence to suggest that the vaccine is protective in the young infant.
From a clinical standpoint though, given the constraints of a busy ED, I find that these young infants are always more difficult to assess, especially when given only a brief opportunity to do so and decision making needs to be expedited. If they are truly "well" appearing, have received one set of pneumococcal vaccination and have good follow up, I am in favor of a "wait and watch" strategy.
At the cost of commiting heresy, even obtaining an early urine analysis/culture may not be warranted in these patients! The recently published multicenter IRIS trials suggest that the risk of renal scarring with acute pyelonephritis does not seem to be related to the duration of fever before initiation of antibiotics[Pediatrics 2008;122;486-490 Early Treatment of Acute Pyelonephritis in Children Fails to Reduce Renal Scarring: Data From the Italian Renal Infection Study Trials]
Le Bonheur Children's Medical Ctr
From: Michael G Tunik <[log in to unmask]>
The study by Carstairs has one of the largest N I have seen which stratifies somewhat by vaccine status. The pneumococcal bacteremia rate - 1 or more vaccine group is 0/833, 0% 95%CI (0-0.8%) No one has a large enough study to compare 0 v 1 v 2 v 3 vaccines. So I would be cautious (agree with Jim Chamberlain) of extending the practice of not obtaining a blood culture to the 2-4 mo (1 vaccine) age group.
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