BACKGROUND: The optimal diagnostic approach to and management of well-appearing, highly febrile young children has been a matter of debate owing to the possibility of clinically inapparent, or occult, bacteremia (OB). The most common causative organism of OB is Streptococcus pneumoniae. Universal immunization with a heptavalent pneumococcal conjugate vaccine (PCV7) has recently been implemented, but there are limited data on the impact of this vaccine on the incidence of OB. OBJECTIVE: To evaluate the incidence of OB in the era of routine use of PCV7. METHODS: We conducted a retrospective cohort study of highly febrile (temperature, 39 degrees C) children between the ages of 2 months and 36 months who had blood cultures performed in the emergency department or urgent care center between December 11, 2001, and March 5, 2003, and were discharged to home at the time of the initial visit. RESULTS: Of 329 blood cultures obtained from children who met inclusion criteria and did not meet exclusion criteria, 3 (0.91%; 95% confidence interval, 0%-1.9%) yielded a pathogenic bacterium; all were S pneumoniae. Neither an elevated total white blood cell count, an elevated absolute neutrophil count, nor an increased percentage of bands was highly predictive of OB. Blood cultures positive for organisms were more commonly due to contaminants (4; 95% confidence interval, 0%-2.4%) than pathogens. CONCLUSIONS: In the PCV7 era, OB is uncommon in highly febrile children 2 to 36 months of age. With continued use of PCV7, the routine practice of obtaining blood cultures and complete blood cell counts may no longer be indicated in previously healthy, well-appearing, highly febrile children 2 to 36 months of age, particularly those who have received at least 1 dose of PCV7.