Designing for Defence: Preventing Hospital-Acquired Infections Through Smarter Infrastructure and Materials
The Healthcare Infection Society (HIS), in collaboration with Sidara (a built-environment specialist), on Thursday 27 March 2025 – brought together infection prevention and control (IPC), clinicians, architects, engineers, healthcare planners and other specialists to discuss ‘The Silent Pandemic’ of AMR. This initiative aims to foster honest, constructive debate and drive practical solutions through shared knowledge and experience. A report followed the workshop that synthesises the key discussions and takeaways from the event, focusing on communication and stakeholders, education, and innovation in hospital design.
Part of the report focussed on Hospital-acquired infections (HCAIs). HCAIs continue to pose a serious challenge across healthcare settings, often leading to avoidable suffering, prolonged hospital stays, and increased healthcare costs. While infection prevention efforts often focus on clinical protocols and hygiene practices, one fundamental factor is routinely underestimated: the design and construction of the hospital itself.
Many healthcare environments are built with minimal input from infection prevention specialists, and as a result, design decisions inadvertently create conditions that enable microbial persistence, proliferation, and transmission. With the threat of antimicrobial resistance (AMR) accelerating globally, rethinking how we design and build healthcare spaces is no longer optional, it is essential.
The built environment is not a passive backdrop, it is an active agent in infection control or infection transmission. Yet, many hospitals still suffer from repeatable design flaws that increase the risk of contamination. These include poor plumbing layouts, high-touch surfaces without antimicrobial protection, the use of inappropriate building materials, and inadequate commissioning of invisible systems like water and air infrastructure.
Flawed Design: The Hidden Threat Behind Many Outbreaks
One of the most significant oversights in hospital design is the specification of plumbing components. For example, the widespread use of flow straighteners and aerators in taps, often chosen for their water-saving potential or aesthetic design, can encourage biofilm formation. These components can trap moisture and debris, providing an ideal breeding ground for bacteria such as Pseudomonas aeruginosa and Legionella pneumophila.
Poor placement of fixtures compounds the problem. Handwash basins installed close to patient beds, or sinks placed directly beneath taps without adequate offset, can lead to splashback and aerosolisation of pathogens. In intensive care settings, even minor splashing can lead to contamination of nearby equipment or patients.
Sustainability initiatives can also create unintended infection risks. Water-saving measures, such as low-flow systems, may inadvertently reduce turbulence in pipes, increasing the likelihood of stagnation and microbial growth. Similarly, air handling systems that recycle air for energy efficiency may not include adequate filtration or monitoring to prevent airborne transmission of pathogens.
Post-Construction Neglect: When Maintenance Falls Short
Even when materials and layouts are carefully selected, failures in post-construction processes can nullify their benefits. Invisible systems such as drainage networks, water reservoirs, HVAC ducting, and insulation, often go uninspected after installation. Routine testing tends to focus on visible areas, while these concealed systems may harbour biofilm, debris, or stagnant zones that allow pathogens to flourish over time.
Additionally, improper commissioning can leave systems vulnerable from day one. For example, water systems that are not flushed correctly, or that are left stagnant during construction delays, can start life already colonised by microbes. The lack of robust protocols and sign-off criteria creates long-term infection vulnerabilities that are difficult to detect until an outbreak occurs.
Design Solutions: Building Infection Prevention into the Blueprint
Several design innovations and strategies are now being promoted to address these issues. One key approach is the use of offset taps and drains, which reduce splashback and droplet spread. This simple architectural detail can dramatically cut down on sink-associated contamination, especially in clinical areas.
The standardisation of plumbing specifications is another critical step. By avoiding high-risk components like flow straighteners, and opting for fixtures tested under real-world clinical conditions, designers can reduce pathogen colonisation points. Furthermore, prefabricated plumbing systems assembled under controlled conditions can significantly reduce the risk of onsite contamination during construction.
Innovative water-free or low-water hand hygiene systems are also being considered. While not suitable for all clinical zones, they may offer a safer alternative in non-critical areas, especially when combined with surface disinfection protocols and antimicrobial materials.
Equally important is the need to involve specialist contractors during the installation of infection-sensitive systems. Trained professionals can ensure proper alignment, commissioning, and testing, avoiding common failures that arise when general contractors are used for specialist work.
Materials Matter: The Case for Antimicrobial Surfaces
Infection prevention must also extend to surface materials. High-touch areas such as door handles, bed rails, light switches, and touchscreen devices are known vectors for microbial transmission. While hand hygiene remains the frontline defence, antimicrobial surfaces offer a critical secondary layer of protection.
Antimicrobial technology can be embedded into plastics, coatings, and composites, actively inhibit the growth of harmful microbes on treated surfaces. These additives work around the clock to reduce the microbial load between cleaning cycles, lowering the overall bioburden in clinical environments.
Where antimicrobial materials are used, traceability is vital. Verification technology enables post-installation verification that antimicrobial treatments have been applied as specified. This is particularly important when the end customer cannot visually distinguish treated from untreated components. Verification technology allows manufacturers and hospital managers to audit installations and ensure infection prevention measures were followed through from specification to build.
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Digital Intelligence: Using AI and IoT to Monitor Hygiene Systems
The workshop, and subsequent report also explored the role of digital technologies in infection control. The integration of AI and Internet of Things (IoT) devices into hospital infrastructure can offer real-time monitoring of water, air, and drainage systems.
For example, sensors placed in water outlets can track flow rates, temperature deviations, and usage patterns, triggering automatic alerts when anomalies are detected, such as stagnation, low flushing frequency, or high microbial risk. AI-driven analysis of HVAC systems can detect filter saturation, airflow anomalies, or temperature zones that support microbial growth.
These technologies reduce human error and allow hospital maintenance teams to act proactively, not reactively. By embedding intelligent systems into the hospital design, facilities can be continuously optimised to maintain a clean and safe environment.
Balancing Sustainability with Infection Control
The push toward net zero healthcare buildings is vital, but it must not compromise patient safety. Energy-efficient designs should be balanced against infection prevention needs. For instance, air recycling should always be accompanied by appropriate filtration, and low-flow systems must be validated to avoid stagnation.
Designing for both environmental and microbiological resilience requires a multi-disciplinary, evidence-based approach, with infection prevention experts contributing from the earliest planning stages.
A Cultural Shift in Procurement and Governance
To prevent repeat errors, healthcare design must become a feedback-driven process. Procurement teams should move beyond cost-focused evaluations and consider long-term infection prevention performance. Design blueprints should be built around risk-reduction principles and verified outcomes, not just regulatory compliance on paper.
Governance structures must also evolve. Infection prevention teams should have sign-off authority for key systems during design changes or cost-saving iterations. Without this oversight, value engineering risks cutting the very measures that protect patients.
Conclusion: Infection Prevention Starts at the Foundation
The findings from the workshop are clear: infection prevention must be designed into hospitals from the ground up. It is not a responsibility that can be delegated to frontline staff after the building is complete. Architecture, materials science, systems engineering, and digital monitoring all play interdependent roles in reducing healthcare-associated infections.
As AMR continues to rise, hospitals must evolve to meet the challenge, not just with better cleaning, but with smarter infrastructure.
