**11. Recommendations for vancomycin dosing**

In case of bacteremia, the dose of IV vancomycin is 15–20 mg/kg/day divided in two or three doses in order to conserve normal renal function. For seriously ill patients such as those with sepsis, meningitis, pneumonia, or infective endocarditis with suspected MRSA infec‐ tion, a loading dose of 25–30 mg/kg (actual body weight) may be considered. Monitoring of vancomycin trough levels is necessary to guide the dosing of this antibiotic. Serum trough levels should be measured prior to the fourth or fifth dose. For serious infections such as bacteremia, infective endocarditis, meningitis, pneumonia, and necrotizing fasci‐ itis due to MRSA*,* vancomycin trough concentrations of 15–20 μg/mL are recommended. Vancomycin trough monitoring is recommended for serious infections, patients who are morbidly obese have renal dysfunction or have fluctuating volumes of distribution. For isolates with a vancomycin MIC ≤ 2, the patient's clinical response should determine the continued use of vancomycin; however, if the patient has not had a clinical or microbio‐ logic response to vancomycin despite adequate debridement and removal of other foci of infection, an alternative to vancomycin is recommended regardless of MIC. For the isolates with a vancomycin MIC >2 μg/mL (e.g., VISA or VRSA), an alternative to vancomycin should be used.

## **12. Prevention**

Decolonization is important to achieve prevention of *S. aureus* bacteremia and other infec‐ tions. The role of decolonization in controlling the spread of *S. aureus* is still unclear. It is also unclear what the optimal regimen is. Options include agents for nasal decolonization such as mupirocin and topical body decolonization with an agent such as chlorhexidine gluconate to target the extra nasal sites. Systemic oral antibiotics can be used for decolonization; however, there are issues that are very important to consider for decolonization, recolonization, and development of resistance. The current guidelines suggest that decolonization be considered in patients with recurrent skin infections or ongoing transmission occurring among house‐ hold contacts despite optimizing wound care and hygiene measures. Hand hygiene consists of soap and water or an alcohol‐based hand rub before and after contact with infected areas. Sharing personal items is discouraged.

As for hospitals, infection control and prevention strategies should include hand hygiene, active surveillance to identify *S. aureus* colonization, and environmental cleaning. Patient bathing with chlorhexidine gluconate in intensive care units leads to a reduction in *S. aureus* colonization and infection. It is felt that bathing with chlorhexidine gluconate is a measure for source control that may lead to less contamination of health care worker hands, thus less con‐ tamination of the environment and the spread of infection to other patients. One additional infection control strategy for years has been to create a vaccination against *S. aureus*. So far, attempts have been unsuccessful, but there is much research in this area.
