The Role of the Surface Environment in Healthcare-Associated Infections

David J. Weber; Deverick Anderson; William A. Rutala


Curr Opin Infect Dis. 2013;26(4):338-344. 

In This Article

Abstract and Introduction


Purpose of review: This article reviews the evidence demonstrating the importance of contamination of hospital surfaces in the transmission of healthcare-associated pathogens and interventions scientifically demonstrated to reduce the levels of microbial contamination and decrease healthcare-associated infections.

Recent findings: The contaminated surface environment in hospitals plays an important role in the transmission of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), Clostridium difficile, Acinetobacter spp., and norovirus. Improved surface cleaning and disinfection can reduce transmission of these pathogens. 'No-touch' methods of room disinfection (i.e., devices which produce ultraviolet light or hydrogen peroxide) and 'self-disinfecting' surfaces (e.g., copper) also show promise to decrease contamination and reduce healthcare-associated infections.

Summary: Hospital surfaces are frequently contaminated with important healthcare-associated pathogens. Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider's hands or gloves that may result in patient-to-patient transmission of nosocomial pathogens. Admission to a room previously occupied by a patient with MRSA, VRE, Acinetobacter, or C. difficile increases the risk for the subsequent patient admitted to the room to acquire the pathogen. Improved cleaning and disinfection of room surfaces decreases the risk of healthcare-associated infections.


Healthcare-associated infections (HAI) remain a major cause of patient morbidity and mortality in the United States with approximately one out of every 20 hospitalized patients developing an HAI. Klevens et al.[1] estimated that in 2002 there were approximately 1.7 million healthcare-associated infections, which resulted in approximately 99 000 deaths. It has been estimated that the source of pathogens causing an HAI in the ICU was the patients' endogenous flora, 40–60%; cross-infection via the hands of personnel, 20–40%; antibiotic-driven changes in flora, 20–25%; and other (including contamination of the environment), 20%.[2] Over the past decade, substantial scientific evidence has accumulated that contamination of environmental surfaces in hospital rooms plays an important role in the transmission of several key healthcare-associated pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), Clostridium difficile, Acinetobacter spp., and norovirus.[3–7] Evidence supporting the role of the contaminated surface environment in the transmission of several key healthcare-associated pathogens is summarized as follows:

  1. The surface environment in rooms of colonized or infected patients is frequently contaminated with the pathogen.

  2. The pathogen is capable of surviving on hospital room surfaces and medical equipment for a prolonged period of time.

  3. Contact with hospital room surfaces or medical equipment by healthcare personnel frequently leads to contamination of hands and/or gloves.

  4. The frequency with which room surfaces are contaminated correlates with the frequency of hand and/or glove contamination of healthcare personnel.

  5. Clonal outbreaks of pathogens contaminating the room surfaces of colonized or infected patient are demonstrated to be due to person-to-person transmission or shared medical equipment.

  6. The patient admitted to a room previously occupied by a patient colonized or infected with a pathogen (e.g., MRSA, VRE, C. difficile, Acinetobacter) has an increased likelihood of developing colonization or infection with that pathogen.

  7. Improved terminal cleaning of rooms leads to a decreased rate of infections.

  8. Improved terminal disinfection (e.g., vaporized hydrogen peroxide) leads to a decreased rate of infection in patients subsequently admitted to the room where the prior occupant was colonized or infected.

Although pathogen transfer from a colonized or infected patient to a susceptible patient most commonly occurs via the hands of healthcare personnel, contaminated hospital surfaces and medical equipment (and less commonly water and air) can be directly or indirectly involved in the transmission pathways. These transmission pathways have been diagramed and these models provide the basis for the development of interventions to disrupt transmission.[5,8] This review will focus on recent literature that demonstrates the importance of surface contamination in hospitals for patient-to-patient transmission of pathogens and scientifically demonstrated interventions to reduce such transmission.