As antimicrobial resistance emerges as one of healthcare’s most pressing challenges, hospitals are being urged to look beyond antibiotic stewardship and examine a frequently overlooked line of defence: environmental hygiene. From contaminated high-touch surfaces to biofilms lurking within hospital drainage systems, the patient environment can become an important pathway for infection transmission. But are healthcare facilities doing enough to address these risks? 

Antimicrobial resistance (AMR) is often discussed in the context of antibiotic misuse, inappropriate prescribing and the development of drug-resistant pathogens. Yet, within healthcare facilities, another critical dimension demands attention: the environment in which patients receive care. 

Every bed rail, bedside table, medical device, handwashing sink and drainage system has the potential to contribute to the transmission of microorganisms. When environmental cleaning and disinfection are inconsistent or inadequately managed, these surfaces and systems can become reservoirs for pathogens, including those resistant to multiple antimicrobial treatments. 

For hospitals already grappling with healthcare-associated infections (HAIs), the implications are significant. Environmental hygiene is no longer simply about maintaining visibly clean surroundings. It is about preventing infections, protecting vulnerable patients and reducing opportunities for resistant organisms to spread. 

According to the World Health Organization’s Global Report on Infection Prevention and Control 2024, HAIs remain a major driver of antimicrobial resistance, reinforcing the importance of effective infection prevention and control (IPC), supported by adequate water, sanitation and hygiene infrastructure. 

The question, therefore, is not whether environmental hygiene contributes to AMR prevention, but whether hospitals are investing sufficient resources, expertise and accountability in making it effective. 

The Overlooked Link Between Environmental Hygiene and AMR 

Michael Rollins, Consultant Healthcare Environment IPC specialist, believes environmental hygiene remains an under-recognised component of infection prevention. 

“Environmental hygiene is a critical but often under-recognised component of antimicrobial resistance (AMR) infection prevention,” he explains. 

Healthcare environments contain numerous potential transmission points. High-touch surfaces, shared medical equipment, sinks and wastewater systems can harbour microorganisms, creating opportunities for cross-contamination between patients, healthcare workers and equipment. 

Pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and Candida auris present particular challenges because of their ability to persist in healthcare environments. 

Tabrikah Mohammed, Founder and Chairperson, Emirates Infection Prevention & Sterilization Society emphasises that environmental hygiene must be understood as part of a wider infection prevention strategy rather than an isolated cleaning activity. 

“Antimicrobial resistance (AMR) is not solely an antimicrobial prescribing problem. Preventing infections and interrupting transmission are equally important, making environmental hygiene a critical component of infection prevention and control (IPC).” 

This distinction is important. Environmental hygiene does not directly eliminate antimicrobial resistance or reverse resistance mechanisms. Instead, it reduces environmental contamination and opportunities for transmission, potentially preventing infections that would otherwise require antimicrobial treatment. 

For hospitals, this makes effective environmental hygiene a preventive intervention with implications extending beyond housekeeping performance. 

Are Hospitals Meeting Basic Cleaning Standards? 

Despite growing awareness of environmental transmission, gaps remain between established cleaning standards and their implementation. 

Rollins highlights findings from a WHO/UNICEF global assessment indicating that fewer than 60 per cent of healthcare facilities met basic environmental cleaning standards. 

Such findings raise concerns about the ability of healthcare systems to manage increasingly complex infection risks, particularly in facilities treating immunocompromised patients or experiencing outbreaks of multidrug-resistant organisms. 

The challenges are not necessarily attributable to an absence of cleaning policies. Many hospitals have established procedures, approved disinfectants and documented cleaning schedules. However, the existence of these systems does not guarantee consistent execution. 

“Having cleaning policies and approved disinfectants does not guarantee effective practice,” Mohammed observes. 

In practice, deficiencies can include high-touch surfaces being missed, inconsistent disinfection procedures, insufficient staff training, unclear responsibilities and inadequate monitoring. 

Environmental services teams may also face considerable pressure to clean patient rooms within limited turnaround times, particularly in high-occupancy facilities. 

This creates a fundamental challenge: hospitals may be measuring whether cleaning has been completed without sufficiently assessing whether it has been performed effectively. 

The Hidden Threat Within Hospital Sinks And Drains 

While contaminated surfaces receive considerable attention, hospital plumbing systems represent a more complex environmental hygiene challenge. 

Handwashing sinks, water traps and wastewater drains can support the formation of biofilms: communities of microorganisms embedded within a protective matrix that can make them difficult to remove. 

These environments may harbour antimicrobial-resistant bacteria and provide conditions that support microbial survival, multiplication and potentially the exchange of resistance genes. 

Rollins identifies sink-associated contamination as an important example of why environmental hygiene requires multidisciplinary intervention. 

“A good example would be the risk of transmission from hand wash sinks and the surrounding ‘splash zone’ contaminated by dispersed droplets from the sink and drain.” 

When water enters a contaminated sink or drain, droplets may disperse microorganisms onto surrounding surfaces. This creates potential transmission pathways that routine surface cleaning alone may not adequately control. 

The challenge extends beyond the responsibilities of environmental services personnel. 

Cleaning and disinfecting a sink and its surrounding surfaces may reduce contamination, but these activities do not necessarily eliminate biofilms within wastewater infrastructure. 

Facilities management teams must therefore collaborate with infection prevention specialists to identify plumbing-related risks and develop appropriate engineering controls. 

In certain high-risk environments, including intensive care units, some healthcare facilities have even adopted sink-removal strategies to reduce opportunities for transmission. 

Such decisions require careful risk assessment, considering patient vulnerability, environmental conditions and the organisms involved. 

Why Cleaning Compliance Does Not Equal Infection Prevention 

One of the most significant weaknesses in hospital environmental hygiene programmes is the reliance on cleaning completion records or visual inspections as indicators of effectiveness. 

A surface may appear clean while still harbouring microorganisms or residual organic material. 

Mohammed points to the limitations of existing monitoring approaches. 

“Fluorescent markers can assess whether selected surfaces have been wiped, while ATP testing measures residual organic material but cannot identify specific pathogens. Neither method independently establishes microbiological safety.” 

Fluorescent markers, for example, can help determine whether cleaning personnel have physically wiped designated surfaces. Adenosine triphosphate (ATP) testing provides an indication of residual biological material. 

However, neither method independently establishes whether a surface is free from clinically significant pathogens. 

A 2025 systematic review published in BMJ Quality & Safety found low-certainty evidence that environmental decontamination may reduce the transmission of multidrug-resistant organisms. 

This reinforces the importance of environmental cleaning while highlighting the difficulties associated with directly linking individual interventions to infection outcomes. 

Hospitals must therefore avoid interpreting improved cleaning audit scores as conclusive evidence of reduced HAIs. 

Instead, environmental hygiene performance should be evaluated through multiple indicators, including cleaning compliance, staff competency, audit findings, corrective actions and relevant infection surveillance data. 

Moving Towards Risk-Based Environmental Hygiene 

Not all areas within a hospital present identical infection risks. 

An intensive care unit treating critically ill patients requires a different environmental hygiene approach from a general administrative area. Similarly, surfaces frequently touched by patients and healthcare workers require greater attention than those with limited contact. 

Rollins advocates a risk-zone-based approach that considers three essential dimensions: patient risk, surface risk and pathogen risk. 

“Healthcare Facilities should incorporate a Risk Zone based approach to Infection Prevention and Patient safety,” he recommends. 

Such an approach allows hospitals to prioritise cleaning frequencies, disinfection procedures, monitoring and resource allocation according to the likelihood and consequences of transmission. 

For example, an environment accommodating immunocompromised patients may require more intensive controls, particularly when resistant organisms have been identified. 

Risk-based cleaning must also account for the compatibility and effectiveness of disinfectants, manufacturer-recommended contact times and the availability of suitable equipment. 

Crucially, hospitals must establish clear responsibilities for cleaning shared medical devices and surfaces between patient interactions. 

Without defined ownership, important tasks can fall between environmental services, nursing and other clinical departments. 

Training, Resources And Accountability: Closing The Gaps 

Environmental hygiene programmes depend heavily on the people responsible for implementing them. 

Yet cleaning personnel are not always provided with the same level of infection prevention training, professional recognition or operational support as other healthcare teams. 

High workloads, insufficient staffing and limited access to appropriate materials can undermine even well-designed cleaning protocols. 

Rollins identifies incomplete training, inconsistent high-touch surface cleaning and inadequate resources as recurring areas requiring improvement. 

“Cleaning and disinfection are primary clinical safety functions working in some cases in isolation rather than an integrated multi-disciplinary approach to environmental infection risk.” 

Addressing these weaknesses requires more than occasional refresher training. 

Environmental services personnel need structured competency assessments, practical instruction, appropriate supervision and regular feedback. 

The US Centers for Disease Control and Prevention identifies several core components of effective environmental cleaning programmes, including integration into organisational safety culture, staff education, appropriate product selection, standardised procedures and monitoring. 

Mohammed similarly stresses the importance of shared accountability. 

“Infection Prevention and Control, Environmental Services, Nursing, Quality and hospital leadership must share accountability.” 

This collaboration becomes particularly important during outbreaks, when environmental contamination may contribute to persistent transmission despite conventional infection control interventions. 

Facilities management also has an essential role in addressing engineering-related risks involving water systems, drainage infrastructure and the built environment. 

Environmental hygiene cannot operate effectively when these functions work independently. 

From Routine Audits To Continuous Improvement 

For hospitals seeking to strengthen their environmental hygiene programmes, structured assessment and benchmarking can provide a starting point. 

The Clean Hospitals organisation in Geneva has developed the Healthcare Environmental Hygiene Self-Assessment Framework (HEHSAF), an online tool designed to help healthcare facilities evaluate their environmental hygiene programmes and identify opportunities for improvement. 

Developed with input from more than 100 infection prevention experts and internationally validated, the framework supports IPC professionals and environmental hygiene managers in reviewing performance and tracking progress over time. 

Its relevance lies in encouraging hospitals to examine environmental hygiene as an organisational system rather than a collection of isolated cleaning activities. 

Mohammed highlights the need to translate assessment findings into meaningful operational improvements. 

“Hospitals should therefore avoid assuming that improved audit scores alone prove a reduction in HAIs.” 

Performance indicators should extend beyond the percentage of completed cleaning tasks to include competency verification, audit outcomes, corrective-action closure and sustained adherence to protocols. 

Monitoring must also generate timely feedback. Identifying deficiencies is only valuable when the findings result in corrective measures, additional training or changes to procedures. 

Importantly, infection surveillance data should inform environmental hygiene decisions, while recognising that patient outcomes are influenced by several interconnected interventions. 

Environmental Hygiene As A Patient Safety Priority 

The growing threat of antimicrobial resistance demands a broader understanding of infection prevention. 

Antimicrobial stewardship remains essential, but responsible prescribing alone cannot prevent resistant microorganisms from spreading through contaminated healthcare environments. 

Environmental hygiene must be recognised as an integral element of clinical safety, supported by appropriate investment, technical expertise and multidisciplinary accountability. 

Rollins reinforces this position by calling for environmental hygiene to be incorporated alongside antimicrobial stewardship, hand hygiene, surveillance and other infection prevention measures. 

“Ultimately healthcare facilities management and Infection Prevention should regard environmental hygiene as an integral component of AMR prevention, alongside antimicrobial stewardship, hand hygiene, surveillance and appropriate clinical infection control measures.” 

For Mohammed, the priority is ensuring that environmental hygiene delivers measurable improvements rather than merely satisfying documentation requirements. 

“Hospitals should move beyond documenting completed cleaning and demonstrate consistent practice, effective monitoring and corrective action.” 

Ultimately, the effectiveness of hospital environmental hygiene cannot be judged by how clean a facility looks, how many cleaning checklists have been completed or how frequently surfaces are disinfected. 

It must be assessed through the consistency of its practices, the competence of its workforce, the effectiveness of its monitoring systems and its contribution to a safer patient environment. 

As antimicrobial resistance continues to challenge healthcare systems worldwide, hospitals cannot afford to overlook the environments in which infections may originate and spread. 

The real question is no longer whether hospitals are cleaning enough, but whether they are cleaning effectively, intelligently and with infection prevention at the centre of every decision.