Synthetic polymer surfaces provide an excellent opportunity for developing materials with inherent antimicrobial and/or biocidal activity, therefore representing an answer to the increasing demand for antimicrobial active medical devices. So far, biologists and material scientists have identified a few features of bacterial cells that can be strategically exploited to make polymers inherently antimicrobial. One of these is represented by the introduction of cationic charges that act by killing or deactivating bacteria by interaction with the negatively charged parts of their cell envelope (lipopolysaccharides, peptidoglycan, and membrane lipids). Among the possible cationic functionalities, the antimicrobial activity of polymers with quaternary ammonium centers (QACs) has been widely used for both soluble macromolecules and non-soluble materials. Unfortunately, most information is still unknown on the biological mechanism of action of QACs, a fundamental requirement for designing polymers with higher antimicrobial efficiency and possibly very low toxicity. This mini-review focuses on surfaces based on synthetic polymers with inherently antimicrobial activity due to QACs. It will discuss their synthesis, their antimicrobial activity, and studies carried out so far on their mechanism of action.