INFECTION CONTROL
BEIPI members at the second London workshop.
A growing body of evidence shows that the hospital
environment, where the most vulnerable patients are located, actively helps pathogens develop resistance. Dr Michael Weinbren, consultant clinical microbiologist and infection control doctor, a specialist advisor to New Hospital Programme, and board member of the Built Environment Infection Prevention Initiative (BEIPI), specialises in AMR in water and wastewater systems. He describes these systems as “an evolutionary accelerator. You’ve got massive amounts of bacteria in there, so you’ve got to think of the wastewater system as a living entity.”7 Water and wastewater systems are woven through the entire body of the hospital building to deliver clean water and to remove waste. Every time a patient on antibiotics uses the toilet, they excrete up to 90 per cent of the antibiotic straight into the wastewater system. Sputum, blood, and other fluids containing infectious bacteria and viruses will find their way into the system via drains. Wastewater pipes provide a comfortably warm, moist environment for AMR microbes to fight and adapt to survive against the antimicrobials they encounter, becoming stronger. Having grown more resistant in the complex pipework of the hospital, these microbes have been shown to travels upwards and back out of drains into patient rooms as the pressure changes in plumbing systems. Plumes of AMR bacteria spray invisibly from toilets, sinks, and shower drains, landing on surfaces and coming into contact with fresh water supply. The water and wastewater system is without doubt the greatest culprit in fostering AMR resistance in hospitals, but risks also stem from elsewhere in the built environment. WHO note that one factor impacting the spread of airborne microbes through the air are the ‘environmental conditions (such as airflow, humidity, temperature, setting, ventilation)’,8
and ventilation systems, fixtures and fittings,
surface position and materials, and the flow of people and equipment through the building can all impact the ability of AMR microbes to find their way to the vulnerable patient population.
Beyond the remit of infection prevention and control Dr Weinbren outlined the physical scale of the problem: “… we worked out that the surface area of bacteria within the wastewater system is greater than a professional football pitch. So it’s a massive breeding ground.” While it is the responsibility of infection control teams to protect patients from infection, to start thinking about this at the point at which patients enter a hospital is too late. It is important for those who commission, design, and build hospitals to understand that the fightback against AMR must be incorporated into hospital design and delivery from day one: “… it can be poor design, it can be poor construction, it can be poor installation. So these things cause infections, but they’re not within the gift of the infection control team to put right,” Dr Weinbren explained.
A multidisciplinary approach is therefore vital – but 50 Health Estate Journal November 2026
readers will be aware of how easy it is to fall into working in silos rather than seeking expertise from unfamiliar faces. John Bodley Scott, a senior design manager at Sisk who specialises in healthcare buildings and BEIPI board member, describes the unique experience of working on a hospital building: “Modern hospitals or modern healthcare designs are very much these enormous ‘machines’… It is a huge beast, and it’s only after several years in the industry that you kind of get your head around that, that you’re really designing for this massive machine that’s being housed within the fabric of the building.” For a ‘once in a lifetime’ project such as a brand-new hospital building, those involved in elements of the process may be embarking on this type of work for the first time. They may then not work on a similar project again, meaning that the knowledge picked up from mistakes made along the way does not always pass along to future projects.
Towards a solution The construction industry in the UK is no stranger to controversy. The Grenfell Tower for years loomed over London as a reminder of the consequences of discarding occupant safety as a core principle. Dr Weinbren argues that the conclusions of the Hackitt report, commissioned in 2017 by the UK Government following the Grenfell fire, contain the necessary principles to apply in the fight against AMR. “I’m fairly sure most of the big companies think the Hackitt Report, because it came out of Grenfell, was about fire safety and high- rise buildings and cladding,” he said. “And it isn’t.” In a compelling argument published in the April issue of Health Estate Journal, he and colleagues argue that the key takeaway for the industry from the Hackitt Report is to reject a culture of ‘box-ticking’ and unthinking compliance with guidance, and instead to embrace accountability, transparency, and a proactive, risk-based approach to hospital construction projects.
Examples of change In many areas of building design, proactive progress has been made which encourages greater interdisciplinary work and which centres on occupant safety. Fire safety and sustainability have been incorporated into the RIBA Plan of Work in response to the dangers posed by the cladding crisis and the climate emergency, and overlays have been developed to address user safety and comfort, such as the Inclusive Design Overlay, or to adapt to innovative new technologies, such as the Smart Building Design Overlay. The Design in Mental Health Network encourages cross-disciplinary understanding and innovation in designing and building spaces which encompass a more positive experience for all occupants, and a safer one for those with mental health issues. The AMR crisis poses a threat of at least the same scale
as the climate emergency. It is a direct and present threat to occupant safety. In response, the Healthcare Infection Society (HIS), a membership organisation representing experts specialising in infection prevention and control
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