**13. Future perspective**

When vancomycin is used but the bacteremia persists, high‐dose daptomycin (10 mg/kg/day), if the isolate is susceptible, in combination with another agent such as gentamicin 1 mg/kg IV every 8 h, rifampin 600 mg PO/IV daily, or 300–450 mg PO/IV twice daily, linezolid 600 mg PO/IV BID, TMP‐SMX 5 mg/kg IV twice daily should be considered. But in case of reduced susceptibility to vancomycin and daptomycin, quinupristin‐dalfopristin 7.5 mg/kg/dose IV every 8 h, TMP‐SMX 5 mg/kg/dose IV twice daily, linezolid 600 mg PO/IV twice daily, or

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

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.

telavancin 10 mg/kg/dose IV once daily may be other options.

**11. Recommendations for vancomycin dosing**

should be used.

128 Frontiers in Frontiers in Staphylococcus Aureus *Staphylococcus aureus*

**12. Prevention**

Sharing personal items is discouraged.

*S. aureus* has had a steady increase in incidence over the last several decades. The higher frequency of artificial catheters, cardiac devices, joints being placed, of skin and surgical site wounds becoming infected, and intervenous drug use all serve as nidi for infection, particu‐ larly bacteremia. The cost and resource burden on health care systems is projected to continue to grow as the number of risk factors increase. There is also the problem to consider of how MRSA initially was only seen in health care settings but now makes up a large percentage of community‐based infections.

What are some of the ways the medical community is working on not only treating but also preventing a much more widespread and resistant phenomenon? The approval of several newer antibiotics to combat serious MRSA infections shown in 2014, and there are a number of prospective antibiotics being studied with the potential to come to market [17]. A con‐ certed effort among medical centers to make improvements at the level of the diagnostic stage (using transesophageal imaging more regularly) will be necessary in order to improve out‐ comes. In a different approach, the relationship among host immunologic factors in conjunc‐ tion with environmental factors would be an additional avenue for exploration and possibly result in additional, nonantibiotic regimens. Continued use and awareness of infection pre‐ vention measures such as use of isolation inpatient and basic hand hygiene are both effective strategies in the greater attempt to not allow the bacteria to morph any and to prevent basic spread of the organism. Finally, there may be a time in the future when the ultimate means of infection control—a vaccination—would become available.
