Change management system ICH – Q10

Change management system – Innovation, continual improvement, the outputs of process performance and product quality monitoring and CAPA drive change. In order to evaluate, approve and implement these changes properly, a company should have an effective change management system. There is generally a difference in formality of change management processes prior to the initial regulatory submission and after submission, where changes to the regulatory filing might be required under regional
requirements.
The change management system ensures continual improvement is undertaken in a timely and effective manner. It should provide a high degree of assurance there are no unintended consequences of the change.
The change management system should include the following, as appropriate for the stage of the lifecycle:
a) Quality risk management should be utilised to evaluate proposed changes. The level of effort and formality of the evaluation should be commensurate with the level of risk;
b) Proposed changes should be evaluated relative to the marketing authorisation, including design space, where established, and/or current product and process understanding. There should be an assessment to determine whether a change to the regulatory filing is required under regional requirements. As stated in ICH Q8, working within the design space is not considered a change (from a regulatory filing perspective). However, from a pharmaceutical quality system standpoint, all changes should be evaluated by a company’s change management system;
c) Proposed changes should be evaluated by expert teams contributing the appropriate expertise and knowledge from relevant areas (e.g., Pharmaceutical Development, Manufacturing, Quality, Regulatory Affairs and Medical), to ensure the change is technically justified. Prospective evaluation criteria for a proposed change should be set;
d) After implementation, an evaluation of the change should be undertaken to confirm the change objectives were achieved and that there was no deleterious impact on product quality.


Application of change management system throughout the product lifecycle

Pharmaceutical Development :-

  • Change is an inherent part of the development process and should be documented;
  • the formality of the change management process should be consistent with the stage of pharmaceutical development.

Technology Transfer:-

  • The change management system should provide management and documentation of adjustments made to the process during technology transfer activities.

Commercial Manufacturing :-

  • A formal change management system should be in place for commercial manufacturing.
  • Oversight by the quality unit should provide assurance of appropriate science and risk based assessments.

Product Discontinuation:-

  • Any changes after product discontinuation should go through an appropriate change management system.

MICROBIAL CONTAMINATION OF COMPRESSED AIR

MICROBIAL CONTAMINATION OF COMPRESSED AIR

Compressed air systems can harbor the nutrients required for microbes to grow; namely water, oil, and warm temperatures. Maintaining a dry water level of -40°F can inhibit the growth of microbes but will not eliminate them. Bacterial spores can be resistant to U.V., desiccation or heat and can remain dormant for long periods, thus creating the potential for a recurring problem. Further, there is another nasty contaminant known as biofilm. Biofilm can have negative effects on the compressed air quality as well. Biofilm creates a safe haven for bacteria and can provide nutrients to bacteria under conditions that might normally be considered too harsh. To learn more about biofilm, read this Microbiology Online article by Fabio Pacheco.

A microbial monitoring program as suggested by the International Society of Pharmaceutical Engineers’ (ISPE) Good Practice Guide – Process Gases, is a practice that any manufacturer using critical air or gas in their process should consider. The Guide goes on to state in Chapter 7, Risk Assessment, Table 7.1:

Microbial Count (Non-sterile applications) – Guideline limits to be established based on product bioburden limits. Typical level NMT 5 cfu/m3
Microbial Count (Sterile Applications) – As per viable particle requirements for Grade area where the product is exposed to the compressed gas (e.g. Grade A, Grade A/B, Grade B or Grade C)
(from US FDA 2004 Aseptic Processing Guidance.)

Due to the lack of definitive limits for microorganisms, many refer to the limits established for cleanroom classifications shown below.

CLEANROOM CLASSIFICATIONS A
CLEAN AREA CLASSIFICATION
(0.5 ΜM PARTICLES/FT3)
ISO DESIGNATION B≥0.5 ΜM PARTICLES/M3MICROBIOLOGICAL ACTIVE AIR ACTION LEVELS C
(CFU/M3)
MICROBIOLOGICAL SETTLING PLATES ACTION LEVELSC,D
(DIAM 90MM; CFU/4 HOURS)
10053,520ee
1,000635,20073
10,0007352,000105
100,00083,520,00010050
All classifications based on data measured in the vicinity of exposed materials/articles during periods of activity.ISO 14644-1 designations provide uniform particle concentration values for cleanrooms in multiple industries. An ISO 5 particle concentration is equal to Class 100 and approximately equals EU Grade A.Values represent recommended levels of environmental quality. You may find it appropriate to establish alternate microbiological action levels due to the nature of the operation or method of analysis.The additional use of settling plates is optional.Samples from Class 100 (ISO 5) environments should normally yield no microbiological contaminants.
RECOMMENDED LIMITS FOR MICROBIAL CONTAMINATION A
GRADEAIR SAMPLE CFU/M3SETTLE PLATES
(DIAMETER 90MM)
CFU/4 HOURS B
CONTACT PLATES
(DIAMETER 55MM) CFU/PLATE
GLOVE PRINT
5 FINGERS
CFU/GLOVE
A< 1< 1< 1< 1
B10555
C1005025
D20010050
These are average values.Individual settle plates may be exposed for less than 4 hours.
Air & Gas Specifications referenced above may be viewed and/or purchased from: ANSI – American National Standards Institute

FDA WARNING LETTER – Shilpa Medicare Limited

Shilpa Medicare Limited FDA Warning Letter 2020

Delivery Method:VIA UPSProduct:Drugs


Recipient:Mr. Vishnukant Chaturbhuj BhutadaManaging DirectorShilpa Medicare Limited

#12-6-214/A1 Hyderabad RoadRaichur 584135 KarnatakaIndiaIssuing Office:Center for Drug Evaluation and Research | CDER

United States


Warning Letter 320-21-01


October 9, 2020


Dear Mr. Bhutada:

The U.S. Food and Drug Administration (FDA) inspected your drug manufacturing facility at Shilpa Medicare Limited, Unit-IV, FEI 3009876430, Plot No. S-20 to S-26, Pharm, Formulation SEZ, TSIIC, Green Industrial Park, Polepally (Village), Jadcherla (Mandal), District Mahabubnagar (Telangana), from February 13 to 20, 2020, and February 24 to 25, 2020.

This warning letter summarizes significant violations of current good manufacturing practice (CGMP) regulations for finished pharmaceuticals. See Title 21 Code of Federal Regulations (CFR), parts 210 and 211 (21 CFR parts 210 and 211).

Because your methods, facilities, or controls for manufacturing, processing, packing, or holding do not conform to CGMP, your drug products are adulterated within the meaning of section 501(a)(2)(B) of the Federal Food, Drug, and Cosmetic Act (FD&C Act), 21 U.S.C. 351(a)(2)(B).

In addition, the inspection revealed that your firm failed to submit an (b)(4) Field Alert Report (FAR) to FDA within three working days of receipt of information concerning significant chemical, physical, or other change or deterioration in a distributed drug product, as required by section 505(k) of the FD&C Act, 21 U.S.C. 355(k) and stipulated by the regulation 21 CFR 314.81(b)(1)(ii).

We reviewed your March 17, 2020, response to our Form FDA 483 in detail and acknowledge receipt of your subsequent correspondence.

During our inspection, our investigators observed specific violations including, but not limited to, the following.

1. Your firm failed to thoroughly investigate any unexplained discrepancy or failure of a batch or any of its components to meet any of its specifications, whether or not the batch has already been distributed (21 CFR 211.192).

Your firm manufactures (b)(4) sterile injectables and solid dosage drug products. You failed to conduct adequate out-of-specification (OOS) and complaint investigations, including the identification of the root cause and timely implementation of effective corrective action and preventive action (CAPA) plans.

a. On June 29, 2019, (b)(4) Tablets batch (b)(4) obtained OOS results for impurity-(b)(4).

Your Phase I investigation confirmed the initial OOS result when the original sample was re-injected and re-filtered. No probable root cause was identified. Also, you did not thoroughly investigate an unknown chromatographic peak observed adjacent to the impurity (b)(4) peak in the High-Performance Liquid Chromatographic (HPLC) run.

You attributed the unknown chromatographic peak to sample contamination or HPLC column load problem, without supporting documentation. You made no meaningful effort to determine if the sample was contaminated. The initial HPLC run that generated the OOS result met the method system suitability requirements and no column or equipment malfunction was reported. Your analyst also reported that the column had been properly flushed. Based on your investigation, the unknown peak was not observed in either the blank or the placebo injections.

During your Phase II laboratory investigation, the HPLC column was reconditioned (i.e., washed for (b)(4)). With no explanation of your rational, on July 9, 2019, you retested batches (b)(4)(b)(4), and (b)(4) using the reconditioned column. The three batches complied with the specification for the impurity-(b)(4). However, you did not include batch (b)(4), which had the original OOS result, in the retest.

Later, batch (b)(4) was retested using a new sample preparation with the reconditioned column. However, this chromatographic run was aborted: reportedly, there was a system communication error. You again reconditioned the HPLC column by washing it with water for (b)(4), followed by (b)(4) washing (b)(4). Batch (b)(4) was retested after the HPLC column was reconditioned multiple times. The impurity-(b)(4) met the specification and product was released.

Your response is inadequate. You did not provide sufficient scientific justification to demonstrate the HPLC column was the root cause of the original confirmed OOS. You did not explain why the unknown chromatographic peak was not observed in the blank or standard solutions. Your investigation is unclear as to why the original sample was not retested using a new HPLC column to rule out sample contamination as the root cause. Your investigation also lacked information about the history and use of the HPLC column, and an evaluation of the analytical method and equipment-column performance.

b. You obtained OOS assay results in three different batches of (b)(4) Injection. The specification is (b)(4)(b)(4)% for both solution and suspension assay.

i. On April 30, 2018, you reported an OOS assay result for batch (b)(4), which failed to meet the (b)(4) solution and suspension specifications. The OOS results reported were (b)(4)% in solution and (b)(4)% in suspension. You concluded that the most probable cause was an error in the preparation of the stock solution, and released the batch based on the average of a (b)(4) retest.
ii. On October 12, 2019, you obtained an OOS assay result for batch (b)(4), which failed to meet (b)(4) solution specifications. The OOS result reported was (b)(4)%. You concluded the OOS was “due to analytical error” and the batch was released.
iii. On October 16, 2019, you obtained an OOS assay result for batch (b)(4), which failed to meet (b)(4) solution specification. The OOS reported was (b)(4)%. You concluded the OOS was due to analytical error, and the batch was released.

In all three investigations you concluded, without adequate scientific justification, that analytical error was the most probable root cause for the original OOS results. Your firm opened CAPA where analysts were retrained to avoid reoccurrence. Your investigations lacked sufficient details of the CAPA implemented and how you will measure the effectiveness of the CAPA. Although you conducted a Phase 2 production review, you did not conduct a comprehensive evaluation of the product development, manufacturing validation, previous failing results obtained, and analytical test method. All three batches were released based on passing retest results.

Your response is inadequate. Although you suggested possible root causes, you provided no scientific evidence to support your conclusions that laboratory errors had occurred. Your firm also failed to provide details of the CAPA implemented and how you measure the effectiveness of CAPA.

c. Your complaint investigation related to (b)(4) Injection (b)(4) mg/(b)(4) mL, batch (b)(4), produced in January 2019 with an expiration date of (b)(4), was inadequate.

On October 2, 2019, a complaint received reported that the “(b)(4) enclosure” system separated from the glass vial. During the manufacture of this batch an unplanned deviation was initiated due to several filled vials showing sealing defects. About an hour after the filling operation started “bad cap rejections” (improper (b)(4)) was observed. The deviation record indicated that the (b)(4) were misplaced/misaligned and that the (b)(4) was not properly locked. According to your complaint investigation a breakdown of the sealing machine had occurred when the product was manufactured and “there might be the probability that few vials with loose sealing might have missed out during visual inspection.” Despite this you released the batch.

We acknowledge that your firm conducted a study after the inspection to assess the integrity of the seal of vials as part of assessment into this issue.

Your response is inadequate. You provide no justification for having released the batch of (b)(4) Injection batch #(b)(4), including the portion filled during the first hour of sealing, when a machine breakdown occurred. In addition, your investigation is silent regarding the vials filled prior to noting the equipment breakdown.

d. You received multiple consumer complaints for batches of (b)(4) Injection related to the presence of foreign particles; these complaints have not been properly evaluated to prevent reoccurrence.

Your investigation concluded, with no scientific evidence, that the root cause was related to the use of a (b)(4) by the end user. You indicated that you evaluated the drug product using (b)(4) and observed no problem, while the complainants used an (b)(4). You do not have sufficient scientific data, including but not limited to functionality test data, to support your root cause that the foreign particles and stopper separations or “seal coring” defects are caused by the use of a (b)(4).

Inadequate OOS investigations is a repeat CGMP violation from the 2017 FDA inspection.

We acknowledge your efforts to remediate your investigation program and your decision to initiate a protocol-based study to evaluate the (b)(4) used by the end user on Shilpa-supplied products.

However, your response lacks adequate details regarding the scope and extent of the remediation.

In response to this letter, provide the following:

• A comprehensive, independent assessment of your overall system for investigating deviations, discrepancies, complaints, OOS results, and failures. Provide a detailed action plan to remediate this system. Your action plan should include, but not be limited to, significant improvements in investigation competencies, scope determination, root cause evaluation, CAPA effectiveness, quality assurance unit oversight, and written procedures. Address how your firm will ensure all phases of investigations are appropriately conducted.

• Provide your market action plan for the batches referenced in this letter and other batches found out of compliance as part of your independent retrospective assessment.

• An independent assessment and remediation plan for your CAPA program. Provide a report that evaluates if staff with proper investigation competencies effectively conducts root cause analysis, assures CAPA effectiveness, regularly reviews investigations trends, implements improvements to the CAPA program when needed, ensures appropriate quality assurance unit decision rights, and is fully supported by executive management.

• A management strategy including the interim measures describing the actions you have taken or will take to protect patients and to ensure the quality of your drugs, such as notifying your customers, recalling product, conducting additional testing, adding batches to your stability programs to assure stability, drug application actions, and enhanced complaint monitoring.

• A retrospective, independent review of all invalidated OOS (including in-process and release/stability testing) results for U.S. products irrespective of whether the batch was ultimately distributed in the U.S. and a report summarizing the findings of the analysis, including the following for each OOS:

    o Determine whether the scientific justification and evidence relating to the invalidated OOS result conclusively or inconclusively demonstrates causative laboratory error.
    o For investigations that conclusively establish laboratory root cause, provide rationale and ensure that all other laboratory methods vulnerable to the same or similar root cause are identified for remediation.
    o For all OOS results found by the retrospective review to have an inconclusive or no root cause identified in the laboratory, include a thorough review of production (e.g., batch manufacturing records, adequacy of the manufacturing steps, suitability of equipment/facilities, variability of raw materials, process capability, deviation history, complaint history, batch failure history). Summarize potential manufacturing root causes for each investigation, and any manufacturing operation improvements.

• A comprehensive review and remediation plan for your OOS result investigation systems. The CAPA should include but not be limited to addressing:
    o Quality unit oversight of laboratory investigations
    o Identification of adverse laboratory control trends
    o Resolution of causes of laboratory variation
    o Initiation of thorough investigations of potential manufacturing causes whenever a laboratory cause cannot be conclusively identified
    o Adequately scoping of each investigation and its CAPA
    o Revised OOS investigation procedures with these and other remediations

For more information about handling failing, OOS, out-of-trend, or other unexpected results and documentation of your investigations, see FDA’s guidance document Investigating Out-of-Specification (OOS) Test Results for Pharmaceutical Production at https://www.fda.gov/media/71001/download.

2. Your firm failed to follow adequate written procedures describing the handling of all written and oral complaints regarding a drug product including the review by the quality control unit of any complaint involving the possible failure of a drug product to meet any of its specifications and, for such drug products, a determination as to the need for an investigation in accordance with 21 CFR 211.192 (21 CFR 211.198(a)).

Your procedure QAD/GEN/049-05 titled “handling of market complaints” indicates if a compliant is assigned a rank of 3 in severity, the complaint should be treated as critical, irrespective of the risk priority number. None of the complaints related to the presence of particles found in your (b)(4) Injection or potential breach of vial integrity of (b)(4) Injection were assigned rank 3. Extrinsic particles or integrity breach could be an indicator of loss of sterility. Instead, the complaints received during the past two years were classified as minor even though some of them were determined by your client as critical complaints and could lead to serious adverse events. You classified the above complaints as minor and no CAPA were implemented.

In your response you acknowledged that complaints associated with particulate contamination, coring, and seal integrity, originally classified as minor, should have been classified as major.

Your response is inadequate. Your response did not provide a scientific justification or rationale for not classifying these complaints as “critical.” Your response also failed to explain the discrepancy between your sponsor’s and your own complaint risk assessment classification.

In response to this letter, provide the following:

• An independent assessment and remediation plan for your complaint handling program. Provide a report that evaluates all CAPA implemented. Include an evaluation of staff competencies, root cause analysis, CAPA effectiveness, regular reviews of investigation trends, improvements to the CAPA program when needed, and review of decisions made by the quality unit to ensure they are scientifically based and supported by executive management.

• An independent retrospective review of all complaints and associated investigations for batches within expiry. This review should focus on the completeness of the investigations and analysis of complaint or reserve samples, particularly for investigations involving more than one complaint.

Field Alert Reporting Violations

The NDA/ANDA Field Alert reporting requirements in 21 CFR 314.81(b)(1)(i) and (ii), effective since May 23, 1985, require holders of NDAs and ANDAs to submit information concerning any bacteriological contamination, or any significant chemical, physical, or other change or deterioration in the distributed drug product, to the appropriate FDA district office within three working days of receipt by the applicant. The intent of the 21 CFR 314.81(b)(1) regulation is to establish an early warning system so that significant problems are brought to the FDA’s attention by applicant holders in order to prevent potential safety hazards from drug products already in distribution and also to prevent potential safety hazards with drug products manufactured in the future. FARs must be submitted for confirmed and unconfirmed problems meeting the definition of the regulation within three working days of a firm’s becoming aware of the problem.

From this inspection, in addition to the aforementioned CGMP violations, your firm is in violation of the Field Alert reporting requirements set forth in 21 CFR 314.81(b)(1)(ii). During 2017 and 2018, FARs related to (b)(4) solution were not provided to FDA within three working days. Specifically, you received several complaints related to extrinsic particles observed in vial(s) of several batches of (b)(4) Injection (b)(4) mg/vial and no FAR was submitted to the agency:

1. On December 5, 2018, you received a customer complaint for batch (b)(4). On December 5, 2018, you acknowledged the complaint and determined that an initial FAR was not required. You investigated the complaint and closed the investigation on February 11, 2018.
2. On November 21, 2018, you received a customer complaint for batch (b)(4). On November 21, 2018, you acknowledged the complaint and determined that an initial FAR was not required. You investigated the complaint and closed the investigation on January 18, 2019.
3. On October 3, 2018, you received a customer complaint for batch (b)(4). On October 3, 2018, you acknowledged the complaint and determined that an initial FAR was not required. You investigated the complaint and closed the investigation on December 3, 2018.
4. On September 10, 2018, you received a customer complaint for batches (b)(4) and (b)(4). On September 11, 2018, you acknowledged the complaint and determined that an initial FAR was not required. You investigated the complaint and closed the investigation on November 2, 2018.
5. On August 31, 2018, you received a customer complaint for batches (b)(4) and (b)(4). On August 31, 2018, you acknowledged the complaint and determined that an initial FAR was not required. You investigated the complaint and the investigation on November 2, 2018.
6. On July 27, 2018, you received a customer complaint for batch (b)(4). On July 27, 2018, you acknowledged the complaint and determined that an initial FAR was not required. You investigated the complaint and closed the investigation on September 22, 2018.
7. On January 6, 2018, you received a customer complaint for batch (b)(4). On January 7, 2018, you acknowledged the complaint. On January 8, 2018, you determined that no initial FAR was required. You investigated the complaint and closed the investigation on February 23, 2018.
8. On December 15, 2017, you received a customer complaint for batch (b)(4). On December 16, 2017, you acknowledged the complaint and determined that an initial FAR was not required. You investigated the complaint and closed the investigation on February 16, 2018.

We are concerned with the CGMP violations demonstrated at your facility and failure to submit FAR-related events within three days of becoming aware of a problem. Please include in your written response the corrective action you plan to take regarding distributed products manufactured at your facility that may be affected by the violations.

CGMP Consultant Recommended

Because you failed to correct the repeat violation from previous inspection, we strongly recommend engaging a consultant qualified to evaluate your operations as set forth in 21 CFR 211.34 to assist your firm in meeting CGMP requirements.

Your use of a consultant does not relieve your firm’s obligation to comply with CGMP. Your firm’s executive management remains responsible for resolving all deficiencies and systemic flaws to ensure ongoing CGMP compliance.

Conclusion

The violations cited in this letter are not intended to be an all-inclusive list of violations that exist at your facility. You are responsible for investigating and determining the causes of these violations and for preventing their recurrence or the occurrence of other violations.

If you are considering an action that is likely to lead to a disruption in the supply of drugs produced at your facility, FDA requests that you contact CDER’s Drug Shortages Staff immediately, at [email protected], so that FDA can work with you on the most effective way to bring your operations into compliance with the law. Contacting the Drug Shortages Staff also allows you to meet any obligations you may have to report discontinuances or interruptions in your drug manufacture under 21 U.S.C. 356C(b). This also allows FDA to consider, as soon as possible, what actions, if any, may be needed to avoid shortages and protect the health of patients who depend on your products.

Until you correct all violations completely and we confirm your compliance with CGMP, FDA may withhold approval of any new drug applications or supplements listing your firm as a drug manufacturer.

Failure to correct these violations may also result in the FDA refusing admission of articles manufactured at Plot No. S-20 to S-26, Pharm, Formulation SEZ, TSIIC, Green Industrial Park, Polepally (Village), Jadcherla (Mandal), District Mahabubnagar (Telangana), India into the United States under section 801(a)(3) of the FD&C Act, 21 U.S.C. 381(a)(3). Articles under this authority may be subject to refusal of admission, in that the methods and controls used in their manufacture do not appear to conform to CGMP within the meaning of section 501(a)(2)(B) of the FD&C Act, 21 U.S.C. 351(a)(2)(B).

After you receive this letter, respond to this office in writing within 15 working days. Specify what you have done since our inspection to correct your violations and to prevent their recurrence. If you cannot complete corrective actions within 15 working days, state your reasons for delay and your schedule for completion.

If you believe that your products are not in violation of the FD&C Act (or you have complied with FDA regulations), include your reasoning and any supporting information for our consideration.

Send your electronic reply to [email protected] Identify your response with FEI 3009876430 and ATTN: Rafael E. Arroyo.

Sincerely,
/S/

Francis Godwin
Director
Office of Manufacturing Quality
Office of Compliance
Center for Drug Evaluation and Research

Reference:- https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/shilpa-medicare-limited-607877-10092020

Sterility Testing in Pharmaceutical Product as per USFDA Guideline

Sterility Testing is defined as a testing which confirms that products are free from the presence of viable microorganisms. Sterility testing is very important for medical devices, pharmaceuticals, preparations, tissue materials and other materials that claim to be sterile or free from viable microorganisms.

Sterility Testing

A. Method Suitability Test

For all product types, follow current USP methodology in <71>, with the following additional instructions.

In all cases, even if the product does not include a preservative, the product itself may have growth inhibiting properties.  All products should undergo a prescribed Method Suitability test.

Units selected for suitability testing should be subjected to the same disinfection procedure utilized in the sample analysis.

When developing the testing protocol for method suitability the volume of product as well as the concentration of the product should be evaluated such that the highest volume of product and the highest concentration of product should be used for the method suitability testing.

If multiple samples of the same product from the same manufacturer (same dosage and form) are collected, one sample may be used for method suitability for all the samples collected.

  1. When to run Method Suitability:
    1. Run the method suitability test prior to conducting the sterility test in accordance with USP requirements under the following conditions:
      1. If insufficient information about the product exists to judge its probable growth inhibiting activity.
      1. In all cases, when there is sufficient analytical time available,

i.e., survey type samples.

  • Run the method suitability test concurrently with product sterility tests when time is critical, and problems associated with 1. above have been resolved.  However, it should be noted that if the Method Suitability Test is run concurrently with the product sterility test and the Method Suitability Test should fail, the results of the product test are invalid and the Method Suitability Test as well as the product test will need to be repeated with proper method modification to neutralize the inhibiting property.
    • If an insufficient amount of product is collected and the analysis is critical, the suitability test can be conducted at the end of the 14-day incubation period. Be sure to use best judgment and maximum neutralization approach when initially conducting the product sterility test. If the suitability results indicate inhibition then the results, if negative, are invalid. However, if the product test results indicate microbial presence and the suitability test shows inhibition, the results are still valid.
  • Method Suitability Test Procedures

Method Suitability and positive culture control tests which require the use of viable microorganisms, should be performed outside the clean room or isolator, in a biosafety cabinet or equivalent.

  1. Membrane filtration
    1. Pass product fluid through filter membrane.  Rinse the membrane with three 100 ml portions (or more if applicable) of specified rinse fluid.  Do not exceed a washing cycle of five times 100mL per filter. This step hopefully will neutralize and remove any antimicrobial residue on the filter membrane.
    1. Add indicated test organisms in specified numbers (less than 100 CFU) into the last 100 ml rinse fluid used. iii. Filter the rinse fluid and aseptically cut the filter membrane into two equal parts, transfer one half into each of two suitable media. If conducting the sterility test using a closed canister system, rinse each canister with the inoculated rinse fluid.
    1. If the available number of test vessels is insufficient for a complete challenge test for each individual microorganism, then the test organisms may be composited as necessary. However, confirmation of growth for the composited microorganisms will need to be performed. 
    1. Confirm composited microorganisms by Gram stain, microscopic examination, and identification after the completion of incubation.
    1. See step c. below for additional considerations.
    1. Direct inoculation:

For direct inoculation, add the test microorganisms to separate test vessels of product and culture media if sufficient product is available.  See step c. below for additional considerations.

  • The following test procedures apply to Direct Inoculation and Membrane Filtration:
    • Inoculate the same microorganism using the same medium without the product as a positive control.
    • For bacteria and fungi, incubate test vessels according to USP requirements. Ensure that seed-lot cultures used are not more than five passages removed from the original master seed-lot. For in-house prepared test strain suspensions of vegetative bacteria and yeast should be used within 2 hours,
 
  

or within 24 hours if refrigerated between 2ºC and 8ºC.  Spore suspensions (A. brasiliensis, B. subtilis, and C. sporogenes) can be prepared and maintained between 2ºC and 8ºC for up to seven days.  Additionally, all bacterial and spore suspensions should be prepared to yield ≤100 CFU.

  1. If growth comparable to that of the positive control vessel without product is obtained, then you may proceed with the sterility test. If comparable visible growth is not obtained, the antimicrobial activity of the product has not been eliminated under the conditions of the test. Modify the test conditions and repeat the Method Suitability test.   
  2. If product is found to exhibit growth inhibiting activity when determined concurrently with product testing, the sterility test must be repeated using a neutralizing agent (or increase media volume) to modify the conditions in order to eliminate the antimicrobial activity.  
  3. Cultures used for the method suitability test can be purchased commercially, ready to use, or can be prepared and maintained locally. Either procedure requires quantitative verification of actual CFU’s inoculated at time of use.   
  4. Sample Analysis
    1. Sample Containers
      1. Open the outer sample packaging on a laboratory bench disinfected with a sporicidal antimicrobial agent. Refer to appropriate literature for choosing suitable antimicrobial agents for use in your facility.
      1. Count the number of units received.  Compare this number with the number of units collected.
      1. Inside the clean room preparation area located outside the ISO 5 area (if available) remove all outer packaging from subsample units that will be tested without compromising the sterile integrity of the product.  Remove sample units and place them on a tray or cart disinfected with an effective antimicrobial agent. Note: One or more units can be sacrificed to aid in the determination for how to aseptically remove test material if the number of the units received is sufficient.
      1. Examine all units visually for container closure integrity, for the presence of any foreign matter in the product and other container closure defects.  Note findings on analyst’s worksheet.
      1. If foreign matter is observed within the primary container, discuss with supervisor the employment of ORS procedure Document ORA-LAB.015 entitled “Screening Protocol for Direct Staining on Products with Appearance of Visible Contamination” (see QMiS for Procedure).
      1. Sample Identification

If sample units are not identified by the collector, the analyst should identify unit with sample #, initials, date, and sub sample # as appropriate for sample traceability. Otherwise, date and initial each unit.

  • Unit Container Disinfection

a. Cleanse the exterior of all product primary containers using antimicrobial/sporicidal agents.  

Depending on the clean room design, immediately move the sample to the clean room on a disinfected designated stainlesssteel cart or place it inside the clean room pass thru for final preparation. If conducting the sterility test in an isolator, place the sample on a designated stainless-steel cart. Allow exposure of the sample to the disinfectant for appropriate time before further handling.  All units should be disinfected appropriately.  The suggested disinfection procedures can be performed on commonly encountered units as follows:

  1. Ampoules can be wiped with lint free sterile towel/wipes saturated with disinfectant.  Ampoules may be soaked in disinfectant/sporicidal following manufacturer’s guidance or laboratory SOP.  
    1. Vials should not be soaked due to the possibility of migration of disinfectant under the closure and into the product.
      1. Laminated Tyvek package composed of polyethylene/plastic laminate can be disinfected with sterile towel/wipes soaked in disinfectant. Tyvek portion lightly scrubbed with sterile particle free dry wipe and air dry in a HEPA filtered laminar flow hood before testing.
      1. Paper Packages can be disinfected with UV light if possible.  Wipe where applicable with sterile particle free dry wipes and air dry as above.
    1. Number of units and/or amount of product tested: 

Follow the current edition of the USP to determine the correct number of units to be tested and the amount of product to be analyzed from each unit. It is preferable to test the entire contents of each unit if possible.  Follow laboratory policy if it requires testing more units than the USP requires.

  • If the number of units collected is less than the USP requirements, discuss with the laboratory supervisor before proceeding.  Samples collected in a for-cause situation may be analyzed with a number of units less than the USP requirements.
  • Preparation for the Analysis
    • Media and Rinsing Fluid Preparation: 

Follow current USP when preparing media used for sample analysis. 

Commercially purchased media may also be used for the analysis. Both prepared and purchased media must meet the requirements of the USP growth promotion test of aerobes, anaerobes and fungi. Media used are:

  1. Fluid Thioglycollate medium (FTM) This medium should be prepared in a suitable container to provide a surface to depth ratio so that not more than the upper half of the medium has undergone a color change indicative of oxygen uptake at the end of the incubation period.  If more than the upper third of the medium has acquired a pink color, the medium may be restored once by heating until the pink color disappears.  Care should be taken to prevent the ingress of non-sterile air during cooling.
    1. Soybean Casein Digest medium (SCD medium) This media must be incubated under aerobic conditions 
    1. Alternative Thioglycollate medium This type of media must be incubated under anaerobic conditions.
    1. Media for Penicillin and Cephalosporin containing drugs.  Add sufficient quantity of sterile Beta-lactamase to the media to inactivate the effect of these antibiotics.
    1. Diluting and rinsing fluids. These fluid rinses may be filtered before sterilization to avoid clogging of the filter membrane during testing.
    1. Media storage

For laboratory prepared media, do not use medium for longer storage period than has been validated.

For commercially purchased media, follow the manufacturer’s recommended storage requirements and expiration date. 

  • Media qualification: 

Perform the following tests on the prepared media before use: 

  1. Sterility: The media batch may be used if the sterilization cycle is validated and monitored with the use of a biological indicator, and the batch passes other quality control testing.  Also, if possible, prior to otherwise concurrently, incubate a portion of the media at the specified temperature for 14 days.
    1. Growth promotion test; follow the current USP using recommended strains of organisms (Table 1, USP <71>).  Do not use cultures that are more than five passages removed from the original master seed lot.  Commercially prepared and standardized stable suspension cultures of the recommended organisms can also be used. Test strains suspensions of vegetative bacteria or yeast should be used within 2 hours, or within 24 hours if refrigerated between 2ºC and 8ºC.  Spore suspensions (A. brasiliensis, B. subtilis, and C. sporogenes) refrigerated between 2ºC and 8ºC may be kept for a validated period of time.   If using commercially prepared organisms, follow the manufacturer’s instructions.   Additionally, all bacterial and spore suspensions should be prepared to yield ≤100CFU. All bacterial counts must be verified at time of use.
    1. Equipment Preparation

Analytical equipment and tools used in sterility analysis and suitability should be cleaned and sterilized using a validated sterilization procedure.  Commercially purchased equipment and tools should be labeled sterile and accompanied by a certificate of analysis for sterility. 

  • Clean Room Activities
    • Gowning

Personnel are critical to the maintenance of asepsis in the controlled environment. Thorough training in aseptic techniques is required.  Personnel must maintain high standards each time they deal with sterile product. 

  1. Personnel gowning qualification should be performed by any analyst that enters the aseptic clean room.  Personnel gowning qualification must consist of:
    1. Training of gowning techniques by a qualified trainer.
    1. Observation of trainee by trainer while gowning. iii. General growth media touch plates utilized to analyze if the trainee gowned correctly without contaminating the sterile outer gown, sterile gloves and sterile head cover.

b. Some consideration should be taken before entering the clean room (see below).  Follow applicable specific procedures for the facility.

  1. Proper gowning immediately prior to entry the clean room is required of all personnel without exception.
    1. Non-linting clean room scrubs that cover as much skin as possible is the ideal inner-suit to wear before gowning up for an aseptic clean room.  Street clothes are not permitted.
    1. Remove jewelry and makeup. iv. Scrub hands (and arms when possible) before gowning. 

v. Non-shedding sterile uniform components should be used all the time. vi. Use aseptic gowning procedure to don sterile uniform components. 

  • Care should be taken to choose gowning that does not expose any skin to the aseptic clean room environment.
    • An appropriate sporicidal/disinfectant is used to sanitize the gloves.  ix. If possible, post the gowning procedures in the gowning room or area to help individuals follow the correct order of gowning.
    • Should an analyst find it necessary to leave the room, he/she should discard all gowning components and put on new ones upon re-entry.
    • If an individual scheduled to enter the clean room for analysis feels sick or has compromised skin, he/she should talk to his/her supervisor to postpone entry into the clean room until fully healed. 
  • Sample Preparation

Repeat disinfection procedure using appropriate

disinfectant/sporicidal immediately prior to placing product primary containers in a working certified laminar flow hood.  Allow all disinfected containers to completely air dry in the laminar flow hood prior to opening for analysis. Alternatively, if conducting the testing in an isolator, place the disinfected items into the isolator and proceed with the local procedures for the proper decontamination of the interior of the isolator. 

  • Room Cleaning After Analysis
    • Remove inoculated tubes of media and all controls from the analytical area by putting them in the pass-thru or on a stainlesssteel cart used for transporting materials in and out of the clean room.
    • After analysis, all sample containers, equipment wrap, used equipment and tools are to be removed from the clean room before the analyst exits.
    • Sample containers used in the analysis should be returned to the original outer containers for storage as part of the reserve sample.
    • Disinfect working area before exiting the clean room.
  • Clean room disinfection and surface monitoring must be conducted for both aerobic and anaerobic microorganisms on a routine basis.  The frequency is to be determined by the local laboratory policy. 
  • Method of Analysis
    • Membrane Filtration

Follow the current edition of the USP for the amount of sample to be tested. 

  • Direct Inoculation

Follow the current edition of USP for the amount of sample and media to be used.  For example: Use 200 ml of each medium when analyzing solid form products. If the membrane filter method is unsuitable, certain liquids may be tested by direct inoculation method.

  • Devices

All devices with only the pathways labeled as sterile are to be tested by the pathway with sterile Fluid D and testing the Fluid D via membrane filtration. 

  • Incubation of Sterility Test Media
    • Incubate Fluid Thioglycollate (THIO) at 32.5 ± 2.5oC. Do not shake or swirl test media during incubation or during examination to minimize aeration of this broth.
      • Incubate Soybean-Casein Digest Broth (SCD) at 22.5 ± 2.5oC. Gentle swirling, on occasion is acceptable to increase aeration of media.
      • Incubation period for THIO and SCD:
        • Not less than 14 days except for products sterilized using ionizing radiation. If tubes are not read on day 14 due to holiday or weekend then record the results, even if positive, on the first available day to observe the tubes.
        • Additional incubation time may be warranted if the analyst is made aware of sterilization processes other than heat or filtration (e.g. 30 days (at minimum) for products sterilized using ionizing radiation).  This is to allow repair of DNA of microorganisms injured by ionizing radiation, if any, that may be present).
  • Analysis of Medical Devices (ex. Purified Cotton, Gauze, Sutures and Surgical Dressings)

The USP method for analysis of surgical dressing/cotton/gauze (in packages) calls for a minimum quantity of 100 mg, to be tested in each medium. It is recommended that an entire unit shall be tested in each medium for individually packaged single-use articles.

1. Gauze, Purified Cotton, Sutures and Surgical Dressings

  1. Using media containers as large as quart jars analyze entire unit of product.
    1. If unit is too large for the container, analyze as much of unit as can be placed in container and covered by the medium.

2. Compositing of Medical Devices

  1. Devices may be tested in composites (2 – 4 units/composite) as long as they meet the specifications of Chapter 71 of the current USP with regards to minimum quantity of a test unit and minimum number of units to be tested. All composited units must be the same lot number.
    1. Devices may be composited only if they successfully pass the Method Suitability test. If composited units do not pass Method Suitability test, then the product cannot be composited.
  2. Control Systems

The objective of a control system is to ensure the sterility, within designated limits, of all items, media, rinsing fluids, and equipment used in a sterility test.

The control systems which will accompany all sterility analyses are outlined below.

1. System Control

A “system control” is used to demonstrate maintenance of sample integrity during all analytical manipulations.  Any piece of equipment that comes in contact with the product under analysis, along with any manipulations by the analysts, must be controlled. Thus, all equipment, fluids, and culture media for the “system control” must be handled in a manner which duplicates, as closely as possible, the manipulations of the actual sample being analyzed.  All materials used as system controls must be sterilized by the analyzing laboratory.  However, the method of sterilization need not be the same as for the product, but they must render the material sterile.

The first choice for the system control is the actual product, if enough test units are available. When complex medical devices must be sacrificed in order to design a suitable sterility test, consider using them for a system control after cleaning, repacking and sterilizing.

When there are viable alternatives, a product unit should not be sacrificed for use as a system control if this will reduce the number of units available for sterility testing below USP requirements or ORS policy requirements, except as provided in the preceding paragraph. If using a product unit would reduce the subsamples examined below the number required by USP or ORS policy, the analyzing laboratory should prepare a control from other material than a unit of the sample product whenever possible.

a. Membrane Filtration: A filter funnel from the vacuum source connection on each manifold used in the test is used for the system control. Alternatively, if a closed canister system is used to conduct the sterility test a canister set from the same lot used during the analysis should be used for the system control. i. Filterable Materials (liquids, soluble solids, etc.)

Use a material similar to the product under test.  The control material must be of the same volume, and similarly packaged as the test product.  Filtersterilized and autoclaved Peptone water (USP Fluid A) may be useful for this purpose in many cases.

ii. Devices with sterile Fluid Pathway

Use tubing or other containers similarly fitted with needles, valves, connectors, etc., as the product under test.  Use USP Fluid D to flush lumens.

b. Materials tested by direct inoculation (devices, insoluble solids, and other non-filterable materials)

Use materials similar in size, shape, and texture, and similarly packaged as product under test.  Replicate as nearly as possible pertinent, unusual features that may reflect on the credibility of the sterility test.

In designing “system controls” for sterility testing, care must be taken to duplicate the sample product for most aspects, as nearly as possible.  Be novel and innovative to meet this requirement and make the system control meaningful.

2. Equipment Controls

All equipment items used in the analysis listed below will be controlled individually.  One item from each autoclave lot of equipment is tested in each medium used in the test. Therefore, for a sample tested in THIO and SCD, one item from each sterilizer load (oven or autoclave) is tested in each medium giving a total of two controls for each forceps, syringe, etc., used in the test.

Forceps

Syringes

Scissors

Scalpels Swabs

Pipettes

Membranes (dry, directly from the package). If membranes are sterilized in place, this control may be omitted. Hemostats

Other special items that may be required by a specific test.

  • Media and Rinse Fluid Controls
    • An uninoculated media and rinse fluid control are analyzed to ensure sterility at time of use.

Alternatively, controls for these materials are accomplished as part of the “system control” for each manifold. This will also include membrane cutters, and other items that contact the product but cannot be individually controlled.

  • Environmental Controls
    • Open Media Controls

Tubes of each medium (THIO and SCD) used in the sterility analysis are exposed to the immediate environment of the test (e.g., laminar flow hood) for the duration of the test. Alternatively, a laboratory may use agar settling plates as detailed in section b.

  • Agar Settling Plates

Plastic Petri dishes containing an effective non-selective medium (based on test requirements) are exposed in the hood for a period not to exceed four hours during the analysis.  After four hours, plates should be replaced to continue monitoring (as appropriate).

Plates should be incubated for 48 hours at 35o C, and an additional 5 days at 25oC in order to detect mold contamination.

  • Controls within an Isolator

When conducting the sterility test within an isolator, if it has been designed to allow for a connection to an air sampler and particle counter this sampling may be performed for the duration of the sample analysis in lieu of the environmental samples described above. If the isolator is unable to accommodate an air sampler and/or particle counter or the instruments are unavailable the environmental controls described in section a. and b. should be used.  Isolator gloves should be examined before and after a testing session to ensure integrity of the gloves were maintained. This examination should be documented. Additionally, prior to each decontamination cycle a leak test of the isolator system must be performed with passing results.

  • Personnel Monitoring

Personnel monitoring must be performed after analysts conclude sterility testing and prior to exiting the aseptic clean room. The analyst shall use general media touch plates to monitor the sterile condition of their clean room attire and to ensure aseptic techniques were followed.

For example, a minimum of five touch plates should be used for the following personnel gowning sites:

RH glove finger tips.

LH glove finger tips. Chest

Left Forearm

Right Forearm

General media touch plates will be incubated for 5 days at 30-35ºC.

NOTE: The numerical values for personnel monitoring limits and specifications are established on the basis of a review of actual findings within the facility.  All isolates are to be identified by local laboratory procedure to ensure that the analyst did not contaminate the sample. Analysts should be sanitizing their gloves throughout the sterility analysis and changing gloves when needed.  However, changing gloves prior to performing personnel monitoring is unacceptable. Each laboratory is required to monitor and trend data to ensure compliance and detect any abnormalities.  H. Sub-culturing Primary Media

Daily observations of primary test media (THIO and SCD) containing product should be performed without unnecessary disturbance.  All handling of positive tubes, streaked plates, or subsequent inoculations of additional media will be done outside the clean room. These culture transfers are to be performed within a HEPA filtered biosafety cabinet or equivalent outside the ISO5 area which has been cleansed with an effective sporicidal/disinfectant anti-microbial agent. The analyst should be gowned with at least sterile gloves, sterile sleeves and a mask to minimize any possible cross contamination.

  1. Record on Analyst’s worksheets the day that the primary isolation media, Fluid Thioglycollate Broth (THIO), or Soybean-Casein Digest Broth (SCD) is turbid and inform supervisor.  Streak tubes on the day they first appear positive and again at 14 days to determine the presence of other possible slow-growing (i.e., fungi) microorganisms.
  2. Within a HEPA filtered biosafety cabinet or equivalent outside the clean room, streak turbid tubes onto Modified Soybean-Casein Digest Medium [SCD broth + 1.5% agar] (Modified SCDA) or other non-selective agar plate.
  3. All streaked plates are incubated for a period at least as long as required for growth in original isolation media (THIO or SCD) not to exceed seven days.
  4. Subculturing from Fluid Thioglycollate Broth (THIO)

a. Subculture Thioglycollate broth to general medium agar plates in duplicate.  Streak two plates; incubate one aerobically, and one anaerobically, each at 32.5 ± 2.5 ºC. NOTE: It is suggested to transfer an aliquot of media from close to the bottom of the tube to maximize the recovery of strict anaerobes.  

  1. Note if any growth is observed on the anaerobic plate which differs from growth on the aerobic plate. Pick a single representative colony and perform an aero-tolerance test in order to determine if a strict anaerobe has been recovered. Proceed with identification of any strict anaerobes recovered when isolation is complete.  
    1. Note if any growth is observed on aerobic plate and compare to growth on anaerobic plates.  Proceed with identification when isolation is complete. 
  2. Subculturing from Soybean Casein Digest broth (SCD)

a. Sub culture SCD broth to general growth medium and incubate aerobically.  Streak one plate; incubate aerobically at 22.5 ± 2.5 ºC.

  1. Note if any growth is observed on general growth medium plate.  Proceed with identification when isolation is complete. 
    1. Each organism should be identified to genus and species, if possible, using rapid identification kits or DNA sequencing.  

I. Product-Induced Turbidity in Primary Test Media

When product-induced turbidity prevents the confirmation of visual observation of growth, the following instructions apply 

  1. Record “T” for any subsample which is turbid due to product-medium mixture. 
    1. On the daily observation page, indicate the meaning of “T” as:  “T = product induced turbidity”. 
    1. At the end of the initial 14 days of incubation, transfer portions of the medium (not less than 1 ml) to a fresh container of the same medium and then incubate the original and transferred containers for not less than 4 days.  Note: Follow the current edition of the USP for any changes concerning subculturing and incubation of turbid samples.
    1. Examine original product inoculated media and the subcultured media for growth daily when possible for not less than 4 days of incubation and record the results on a new daily observation continuation sheet.

Antimicrobial Effectiveness Testing (USFDA)

Antimicrobial Effectiveness testing is described in USP <51>.  Previously this chapter was known as “Preservative Effectiveness Testing”. Detailed procedure for the performance of the test can be found in USP <51>.

Antimicrobial Effectiveness Testing
  1. Media

For the cultivation of the test organisms, select agar medium that is favorable to the rigorous growth of the respective stock culture. The recommended media are Soybean Casein Digest Agar/Broth and Sabouraud’s Dextrose Agar/Broth.  Add a suitable inactivator (neutralizer) for the specific antimicrobial properties in the product to the broth and/or agar media used for the test procedure whenever needed.

  • Growth Promotion of the Media

Media used for testing needs to be tested for growth promotion by inoculating the medium with appropriate microorganisms. It is preferable that test microorganisms be chosen for growth promotion testing (Section D).

Solid media tested for growth promotion is to be set up using the method that will be used to analyze the product (pour plate or spread plate) to determine a microbial plate count (CFU) which must be ≥ 50% of the microorganism inoculum’s calculated value.

  1. Suitability of the Counting Method in the Presence of Product

For all product types, follow current USP methodology in chapter <51>, with the following additional instructions.

Prior to the Antimicrobial Effectiveness testing, determine if any antimicrobial properties exist by performing a Suitability testing utilizing microorganisms used for product testing (section D).  Should the Suitability Test fail the results of Suitability test are invalid and will need to be repeated with proper method modification to neutralize the inhibiting property.

If multiple samples of the same product from the same manufacturer (same amount and form) are collected, one sample may be used for method suitability for all the samples collected.

  • Test Organisms

All cultures must be no more than 5 passages removed from the original stock culture.

  1. Candida albicans (ATCC No. 10231)
  2. Aspergillus brasiliensis (ATCC No. 16404) 
  3. Escherichia coli (ATCC No. 8739)
  4. Pseudomonas aeruginosa (ATCC No. 9027)
  5. Staphylococcus aureus (ATCC No. 6538)

E. Preparation of Inoculum

Preparatory to the test, inoculate the surface of the appropriate agar medium from a recently grown stock culture of each of the above test microorganisms.

Use Soybean-Casein Digest agar for Escherichia coli ATCC 8739, Pseudomonas aeruginosa ATCC 9027 and Staphylococcus aureus ATCC 6538 and incubate at 32.5 ± 2.5° C for 3 – 5 days.  Use Sabouraud Dextrose agar for Candida albicans ATCC 10231 and Aspergillus brasiliensis ATCC 16404 and incubate at 22.5 ± 2.5° C for 3 – 5 days for Candida albicans and 3 – 7 days for Aspergillus brasiliensis.

Harvest the cultures by washing the growth with sterile saline to obtain a microbial count of about 1×108 CFU/mL (see Microbial Enumeration Tests <61> and Tests for Specified Microorganisms <62>). For the A. brasiliensis ATCC 16404 culture, use sterile saline containing 0.05% polysorbate 80.

Alternatively, cultures may be grown in a liquid medium, i.e. Soybean Casein Digest Broth or Sabouraud’s Dextrose Broth, (except for the A. brasiliensis ATCC 16404 culture) and harvested by centrifugation, washing and suspending in sterile saline to obtain a count of about 1 X 108   colony forming units (CFU) per mL.

The estimate of inoculum concentration may be obtained by turbidimetric procedures for the challenge microorganisms and later confirmed by plate count.

Refrigerate the suspension if not used within 2 hours at 2-8° C.

Determine the number of CFU/mL in each suspension using the appropriate media and recovery incubation times to confirm the CFU/mL estimate.

Use bacterial and yeast suspensions within 24 hr. of harvest. The mold preparation may be stored under refrigeration (2-8° C) for up to 7 days. Note:  Alternative commercially available standardized cultures may be used in lieu of in-house prepared cultures.

F. Procedure

The procedure requires that the test be conducted with a suitable volume of product.  It is advisable to begin with at least 20 mL of product.  Use the original product containers whenever possible or five sterile, capped bacteriological containers of suitable size into which a suitable volume of product has been transferred. If the diluted product exhibits antimicrobial properties, specific neutralizers may need to be incorporated into the diluents or the recovery media. For purposes of testing, products have been divided into four categories:

Category 1 – Injections, other parenteral including emulsions, otic products, sterile nasal products, and ophthalmic products made with aqueous bases or vehicles.

Category 2 – Topically used products made with aqueous bases or vehicles, non-sterile nasal products, and emulsions, including those applied to mucous membranes.

Category 3 – Oral products other than antacids, made with aqueous bases or vehicles.

Category 4 – Antacids made with aqueous bases or vehicles.

Inoculate each container with one of the prepared and standardized inoculums and mix.  The volume of the suspension inoculums used is 0.5% to 1.0% of the volume of the product. The concentration of the test organisms added to the product for Categories 1, 2 and 3 is such that concentration of the test preparation immediately after inoculation is between 1×105 and 1×106 colony forming organisms (CFU) per mL of product.  If no suitable neutralizing agent or method is found and method suitability requires significant dilution, a higher level of inoculum (e.g., 107-108) may be used so that a 3-log unit reduction can be measured.  For category 4 products (antacids) the final concentration of the test organisms is between 1×103 and 1×104 CFU/mL of product.  

Immediately determine the concentration of viable organisms in each inoculum suspension and calculate the initial concentration of CFU/mL by the plate count method (see Microbial Enumeration Tests <61>).

Incubate the inoculated containers between 22.5 ±2.5°C in a controlled environment (incubator) and sample the container at specified intervals.  The container sampling intervals include: Category 1 products are sampled at 7, 14, and 28 days and Category 2 – 4 products are sampled at 14 and 28 days.  Refer to table 3 within USP <51>. Record any changes in appearance of the product at these intervals.   Determine the number of viable microorganisms per mL present at each of these sampling intervals by the plate count method utilizing media with suitable inactivator (neutralizer).  Calculate the change in log10 values of the concentration per mL based on the calculated concentration in CFU/mL present at the start of the test for each microorganism at the applicable test intervals and express the changes in terms of log reductions.

NOTE: The USP does not require a specific volume of product to be added to each of the five sterile tubes.  It is recommended that 20 mL/tube be used to standardize testing for all ORS laboratories.

NOTE:  All plate counts should be performed in duplicate (2 plates per dilution), and in a dilution series to detect growth inhibited by the preservative system at the lower dilutions.  Carrying the test to the 10-3 dilution would be sufficient in most cases to overcome preservative inhibition. G. Interpretation

The criteria for microbial effectiveness are met if the specified criteria are met, see table below. No increase is defined as not more than 0.5 log10 unit higher than the previous value measured.

Antimicrobial Effectiveness testing Product Category:-

 Category 1 Products
Bacteria:Not less than 1.0 log reduction from the initial calculated count at 7 days, not less than 3.0 log reduction from the initial count at 14 days, and no increase from the 14-day count at 28 days.
Yeast and Molds:No increase from the initial calculated count at 7, 14, and 28 days.
 Category 2 Products
Bacteria:Not less than a 2.0 log reduction from the initial count at 14 days, and no increase from the 14-day count at 28 days.
Yeast and Molds:No increase from the initial calculated count at 14 and 28 days.
 Category 3 Products
Bacteria:Not less than a 1.0 log reduction from the initial count at 14 days, and no increase from the 14-day count at 28 days.
Yeast and Molds:No increase from the initial calculated count at 14 and 28 days.
 Category 4 Products
Bacteria, Yeast and Molds:No increase from the initial calculated count at 14 and 28 days.

Cleaning Validation Protocol Format

A cleaning validation protocol format shall be developed for the ‘worst case’ product selected for cleaning validation programme.

Following information (but not limited to) the following included in the cleaning validation protocol.

Numbering of protocol shall done through of respective SOP of Cleaning Validation Protocol Numbering.

Cleaning Validation Protocol Format –

Objective:

A brief description of the purpose of the validation study.

Scope:

This section must include an extent of the cleaning validation protocol.

Responsibilities:

This section includes the different responsibility for completing the cleaning validation programme.

Training:

Provided to all personnel involved in the cleaning validation

Record –Training

Records of training of all personnel involved in the cleaning validation program for understanding and cGMP requirement.

Protocol signature log:

Signature (specimen) of all the person involved in the cleaning validation program mention here for proper identification of person for future reference.

Cleaning Procedure:

Brief description of equipment used for selected product & relevant SOP for equipment cleaning. provide the complete details of cleaning procedure in this part of cleaning validation protocol format.

Sampling Procedure:

Swab samples shall taken after final cleaning of the equipment and once the equipment qualifies the visual inspection test. Sampling procedure should be defined in the protocol.

  • Sampling:
    • Visual Inspection
    • Preparation of swab
    • Dimension of swab sample area.
    • Swab Sampling point

Sampling strategy shall be defined in this part of cleaning validation protocol format.

Documentation

While performing each activity, documentation of the required details shall be done in appropriate attachment of this protocol.

Analytical and microbiological test method:

This section will give references for the adopted analytical and microbiological test method to analyse the samples.

The analytical method must validated for the residue levels, or bio-burden as per the specification given in the protocol. Testing performed by.

All test results must calculated and reported to correspond with the predetermined acceptance criteria.

Validation report

Validation report addressing the cleanliness of each piece of equipment shall generated after compilation of three batch validation.

Acceptance criteria:

The acceptance criteria for the cleaning validation will mentioned in the

specific protocol and will decided based on product matrix.

Deviation:

Any deviation taken during execution of the protocol shall documented in this section.

Justification for the deviation will be authorized by Quality Assurance (QA) Head and Factory Head (Plant Head).

ANALYTICAL METHOD DEVELOPMENT AND VALIDATION

  • The development and validation of analytical procedure for the purpose of analyzing cleaning validation sample requires the selection of appropriate tests.
  • Definition of test :
    • Limit of Quantification:
      • The limit of quantification of an individual analytical procedure is the lowest amount of analyte in a sample, which can be quantitatively determined with suitable precision and accuracy.
      • RSD of area of triplicate injections, Not more than 10.0%
    • Limit of Detection:
      • The limit of detection of an individual analytical procedure is the lowest amount of sample concentration till the peak detects in all of the triplicate injections.
    • Linearity:
      • The linearity of an analytical procedure is its ability (within a given range) to obtain test results, which are directly proportional to the concentration of analyte in the sample at LOQ level.

Correlation coefficient in the range of LOQ to 150% of sample concentration should be less than                                        0.990 and graph shall be visually linear.

  • Instrument Precision and Accuracy and Precision at LOQ Level.
    • This study to check instrument repeatability, method repeatability and accuracy. RSD of area from six replicate injections of standard preparation (at LOQ): Not more than 10%. RSD of % recovery calculated from six replicate sample preparation at LOQ concentration is not more than 10 %.
    • Recovery from placebo at LOQ concentration should be between 80.0 % and 120.0 % .
  • Stability in Analytical solution at room temperature:
    • Analytical solution stability at room temperature shall performed.
    • Stability in analytical solution at room temperature for standard and sample preparation between Initial and specified stability time interval is not more than 10 %.
  • Recovery from spiked swabs:
    • The recovery from spiked swab at LOQ (100%) to different concentration is Not less than 80%.
  • Recovery Study from SS Plate:
    • This study is performed for efficiency checking of swab sampling procedure from the surface by applying the known concentration of standard solution on surface at target and LOQ level. Mean recovery from SS plate is not less than 70.0%. Recovery factor should be considered for evaluation of cleaning validation results.
  • Note : Limits for the carryover of product residues should be based on a toxicological evaluation. The justification for the selected limits should be documented in a risk assessment which includes all the supporting references. Limits should be established for the removal of any cleaning agents used. Acceptance criteria should consider the potential cumulative effect of multiple items of equipment in the process equipment train.

MYTH AND FACTS OF CLEANING VALIDATION.

Myth 1 : “You can’t validate manual cleaning”

Fact :

Automated and manual Cleaning Procedure can be validated.

Actually manual cleaning variability is more as compare to the automated cleaning processes,

Consistency of manual cleaning is depends upon

  • the complete details mentioned in cleaning procedures,
  • trend manpower and
  • adequate cleaning steps.

If cleaning procedure steps are robust, cleaning variability will be minimum. It requires more vigilant to validation maintenance. Design a comprehensive, dependable cleaning validation program.

Myth 2 : During recovery at different spiked level should linear.

Fact : Recovery (in %) are highly variable. It is not reasonable to expect linear response, Swabbing is a manual procedure so variability will be there.

Myth 3 : Any residue is unaccepted.

Fact :

In the current methodology (by TOC or By HPLC)  of evaluation of residue content, there will always be some residue obtained in result.

Detection limits of Analytical procedure actives the lower levels.

If the residue obtained is below the acceptable level, and medically safe and it don’t impact on product quality, same quantity of residue can be accepted.

Myth 4 : For Evaluation of Samples, Always use HPLC instead of TOC.

Fact : 

Perform the Evaluation through validated TOC analyzer

No need to re perform the evaluation with HPLC separately and no need to correlate the result generated by TOC with HPLC.

Method validation of TOC with appropriate standards is sufficient to run the sample on TOC.

No need to perform the test individually, both Analytical procedure by HPLC and by TOC can accepted.

Myth 5 : Always correlate rinse sample results with swab sample results.

Fact :



The rinse samples are different with swab samples, there will be no correlation among the both.

Actually swab focus on small area and rinse focus on larger area, where simulation of surface is not possible for swab sample or difficult to reach areas,

Rinse sample for the same. Swab measures worst case and rinse measures average.

SOP on Site Master File (SMF) Preparation

Standard Operating Procedure (SOP) and Guideline for preparation, approval, and revision of Site Master File (SMF). The Site Master File (SMF) Document shall contain specific information about the quality management policies, activities of the site, the production and/or quality control, pharmaceutical manufacturing operations, and any closely integrated operations at adjacent and nearby buildings.

Guideline for Preparation of Site Master File (SMF)

PURPOSE:

  • The purpose of this SOP is to provide the procedure for preparation, approval, and revision of Site Master File (SMF) at the pharmaceutical drug manufacturing site.

SCOPE:

  • The Site Master File (SMF) Document shall contain specific information about the
  • Quality management policies,
  • Activities of the site,
  • Production
  • Quality Control,
  • Pharmaceutical Manufacturing Operations, and
  • Any closely integrated operations at adjacent and nearby buildings.
  • If only part of a pharmaceutical operation is performed on-site, a Site Master File (SMF) shall only describe those specific operations (i.e., analysis, packaging, etc.).

SITE MASTER FILE (SMF):

  • CCR: Change Control Record
  • cGMP: Current Good Manufacturing Practices
  • SMF: Site Master File
  • DEFINITION:
  • Batch (or Lot):
  • A specific quantity of material produced in a process or series of processes so that it is expected to be homogeneous, to have uniform composition, character, and quality within specified limits, and is produced according to a master manufacturing order.
  • Bulk:
  • Any product that has completed all processing stages up to, but not including, final packaging.
  • API –Active Pharmaceutical Ingredient:
  • An ingredient intended to furnish pharmacologic activity or other direct effects in the diagnosis, cure, mitigation, treatment, or prevention of disease or to affect the structure or any function of the body; it does not include intermediates used in the synthesis of such an ingredient.
  • Corrective Action/Preventive Action:
  • A concept with current Good Manufacturing Practice (cGMP) that focuses on the systematic investigation of root causes of unexpected incidences to prevent their recurrence (corrective action) or to prevent their occurrence (preventive action). (SOP for CAPA)
  • Corrective Action:
  • Action is taken to eliminate the causes of an existing nonconformity, defect, or other undesirable situation, in order to prevent a recurrence.
  • Preventive Action:
  • Action is taken to eliminate the cause of a potential nonconformity, defect, or other undesirable situation, in order to prevent occurrence.
  • cGxP:
  • cGxP is a general term that stands for current Good “x” Practice (x = Clinical, Engineering, Laboratory, Manufacturing, Documentation, Pharmaceutical, etc.).
  • The titles of these Good “x” Practice guidelines usually begin with “Good” and end in “Practice”. cGxP represents the abbreviations of these titles where “x” a common symbol for a variable, represents the specific descriptor.
  • Change Control:
  • A formal procedure for proposing, assessing, documenting, and approving changes that could affect the safety, purity, quality, or identity of the product, or could affect the validation of a process or testing methods.
  • Drug Product:
  • A finished dosage form, for example, tablet, capsule, solution, etc., that contains an Active Pharmaceutical Ingredient(s) (API) generally, but not necessarily in association with inactive ingredients.
  • The term also includes a finished dosage form that does not contain an active ingredient but is intended to be used as a placebo.
  • Equipment:
  • A device that operates either as a ‘stand-alone’ or combines several instruments or pieces of equipment to give an output.
  • The equipment performs a unit operation or many unit operations.
  • Parametric Release:
  • A system of release that gives the assurance that the product is of the intended quality based on information collected during the manufacturing process and on the compliance with specific GMP requirements related to Parametric Release.
  • Quality Risk Management:
  • Quality Risk Management is a systematic process for the assessment, control, communication, and review of risks to the quality of drug products across the product lifecycle. (SOP for Quality Risk Management)
  • Site Master File (SMF) :
  • A document in the pharmaceutical industry, which provides information about the production and control of manufacturing operations.
  • The document is created by a manufacturer.
  • Validation Establishing documented evidence, which provides a high degree of assurance that a specific process will consistently produce a product meeting its predetermined specifications and quality attributes.

6.0   PROCEDURE FOR PREPARATION OF SITE MASTER FILE (SMF):

  • Site Master File (SMF) Key Elements:
  • General Information of the Manufacturer
  • Quality Management System of the Manufacturer
  • Personnel
  • Premises (Facility) and Equipment
  • Documentation
  • Production
  • Quality Control (QC)
  • Distribution, Complaints, Product Defects, and Recalls
  • List of GMP inspections of the site within the last 5 years
  • Self-Inspections
  • Site master file (SMF) appendix shall include the following information/documentation:
  • Copy of Valid Manufacturing Authorization…………………………………………..Appendix 1
  • Copy of Valid GMP Certificate………………………………………………………………Appendix 2
  • List of dosage forms and molecules manufactured including the INN-names or common name (as available) of Active Pharmaceutical Ingredients (API) used…………………….. Appendix 3
  • Layouts of Production area (Man & Material movement)…………………………Appendix 4
  • Contract Agreement, List of contract manufacturers and laboratories including the addresses and contact information, and flow-charts of the supply chains for these outsourced activities…………Appendix 5
  • Organizational Charts…………………………………………………………………………..Appendix 6
  • List of Key Personnel……………………………………………………………………………Appendix 7
  • Schematic drawings of the water system(s)…………………………………………….Appendix 8
  • List of Major Production and Laboratory Equipment………………………………Appendix 9
  • List of AHU with serving area……………………………………………………………….Appendix 10
  • Flow chart of Tablet, Capsule, Bottle filling, and sachet……………………………Appendix 11
  • What is the Site Master File (SMF)?
  • The document prepared by the manufacturer, containing specific and factual Good Manufacturing practices (GMP) information about the production and the control of pharmaceutical products at the site.
  • The Site Master File (SMF) shall provide clear information regarding GMP related activities that can be useful in the general supervision and in the efficient planning and undertaking of GMP inspections.
  • Contain adequate information but not to exceed 25-30 pages plus appendices.
  • Simple plans outline drawings, or schematic layouts, are preferred instead of narratives.
  • The Site Master File (SMF), including appendices, shall be readable when printed on A4 paper sheets.
  • When submitted to a regulatory authority, the Site Master File (SMF) provides information on the manufacturer’s operations and procedures that can be useful in the efficient planning and undertaking of a GMP inspection.
  • The SMF shall be prepared/reviewed once a year, preferably in the month of January of every year.
  • The Site Master File (SMF) shall be part of documentation belonging to the Quality Management System and updated accordingly when necessary.
  • The numbering System for Site Master File (SMF) shall be as follows:
    • XX/SMF/YYYY/ZZ      
  • Where:       
  • XX- stands for short name of company/site
  • SMF- stands for Site Master File
  • YYYY: Current Year (e.g. 2020)
  • ZZ- stands for Revision number in ascending order starting with 00
  • Any modifications thereafter shall be addressed as amendments to the SMF & reference change control details to be mentioned in the revision history.
  • Any modification in the annexures shall be revised separately, no need to revise SMF.
  • As and when SMF is revised, accordingly Annexures No. shall be revised with 00 revision suffix to the current revision no. of SMF.
  • Wherever possible, simple plans, outline drawings, or schematic layouts shall be used instead of narrative.
  • The Site Master File (SMF) shall be prepared by QA Head, Approved by the Quality head and Plant Head.
  • Each section of the SMF shall start on a new page.
  • The first approval page of the Site Master File (SMF) shall be signed by the QA head, Head-Quality, and Plant Head.
  • First Page of the Site Master File (SMF) shall contain the following headings:
    • Name and Address of Site
    • Title: Site Master File (SMF) 
    • Document Number, i.e. XX/SMF/YYYY/ZZ 
    • Effective Date and Next Review Date.
  • A separate index shall be prepared for Annexures and Amendment(s) as per Annexure-2 & Annexure-3 respectively.
  • The amendment can be in the form of printed formats, layouts, handwritten information, etc.
  • The Site Master File (SMF) shall be prepared on A4 paper using the following parameters:
ParameterRequirement
Paper SizeA4 paper (210 X 297 mm)
Paper MarginTop 0.7’’Bottom 0.5’’
Left 1.2’’Right 0.5’’
Header & FooterHeader : 0.8”                         Footer : 0.5”
Paper QualityWhite paper with Company Logo
Header Text<Company Name> Font: Times New Roman, Font Style: Bold, Font Size: 14, Alignment: Center
Manual Sub HeadingFont: Times New Roman, Font Style: Bold Font Size: 12, Alignment: Center
Footer TextPage X of Y
* Adjust the header/footer in such a manner that the logo is not covered by Header text.
  • The Site Master File (SMF) shall be prepared with the following headings and details in the header.
<Company Name> <Company Address>
Site Master File (SMF) 
Document No.:TitleIssue Date:
Section No.:Effective Date:
Supersedes:Next Review Date:
  • Where,
  • Document No.: This is the unique alphanumeric identification number allotted to the Site Master File (SMF).
  • Section: This shall be the serial number of that particular section. (Refer point no.)
  • Supersedes: In case of revision of SMF, mention the SMF No. of the superseded SMF. In the case of new SMF, mention “NA”.
  • Issue Date: The date on which the Site Master File (SMF) is approved by Quality Head, the same date shall be handwritten on all respective pages. The date format shall be DD/MM/YY.
  • Effective date: The date on which the Site Master File (SMF) is approved by Factory Head, the same date shall be handwritten on all respective pages. The date format shall be DD/MM/YY.
  • Next Review Date: Next Review date is the date before which the Site Master File (SMF) shall be reviewed. The date shall be handwritten in DD/MM/YY format.
  • The Next review date shall be one year from the effective date, which shall be handwritten on all respective pages.
  • Title: This shall include the headings for that particular section.
  • The footer for Site Master File (SMF) shall include page numbering in the form of Page X of Y, where X is the page number and Y is the total number of pages of Site Master File (SMF).
  • The Site Master File (SMF) shall have the index page with the following details but not limited to :
SectionTitlePage No.
C1General Information
C1.1Company’s Profile
C1.2Name and Address of Site
C1.3Manufacturing Activities
C1.4Other Manufacturing Activity at Site
C1.5Types of Product Manufactured
C1.6Description of the Site
C1.7Employment at Site
C1.8Use of Out Side Technical Services
C2Quality Management System
C2.1Release Procedure of Finished Products includes the following
C2.2Management of Suppliers and Contractors
C2.3Quality Risk management
C2.4Annual Quality review
C3Personnel
C3.1Organogram
C3.2Key Personnel (Qualifications, Experience, and Responsibilities)
C3.3Training
C3.4Health Requirements for personnel engaged in manufacturing activity.
C3.5Personnel Hygiene Requirement Including Clothing
C4Premises & Equipment
C4.1Description of Manufacturing Areas (Man and Material Movement)
C4.2Nature of Construction and Finishes
C4.3Design Criteria For Ventilation Systems Schematic Diagram For HVAC and Dust Extraction System
C4.4Special Area for the handling of highly toxic, hazardous, and sensitizing materials
C4.5Brief Description of Water System and Other Utilities
C4.6Planned Preventive Maintenance for Premises and utilities
C4.7Description of Major Equipment for Production, Quality Control Laboratory & Engineering Equipment
C4.8Planned Preventive Maintenance for Equipment
C4.9Qualification, Validation, and Calibration
C4.10Cleaning and Sanitation.
C4.11GMP Critical computerized systems
C5Documentation
C5.1Preparation, revision, and distribution of necessary documentation for manufacturing
C5.2Other documentation related to product quality
C5.3Additional Documentation
C6Production
C6.1Brief description of production operation
C6.2Arrangement for the handling of starting material, packaging material, bulk and finished product including sampling, quarantine, release, and storage
C6.3A brief description of the arrangement for the handling of rejected materials and products
C6.4Brief description of general policy for process validation
C6.5Describe Policy for Reprocessing or Reworking
C7Quality Control
C7.1Description of the Quality Control System and of the activities of the Quality Control Department & Procedures for the release of finished products
C8Distribution, Product Defect, Complaint, and Product Recall
C8.1Description of Storage and Distribution Practices
C8.2Handling of Product Defects, Complaints, and Product Recall
C9Self Inspection
C9.1Description of Self Inspection Program
C9.2Regulatory inspection
List of Annexures
A separate index for Amendment
  • C1 – General Information – Site Master File (SMF):
  • C1.1 – Company’s Profile: (NMT 250 words/one A4 page)
  • This shall include brief information about the organization, other sites, and information regarding the manufacturing activities at the company.
  • C1.2 – Name and Address of Site:
  • Name, and official address of the company’s manufacturing site contact person (s).
  • Names, and street addresses of the site, buildings, and production units located on the site.
  • Contact information for the manufacturing site, including twenty-four (24) hour telephone number, email address of the contact person in the case of product defects or recalls.
  • Identification number of the manufacturing site such as Global Positioning System (GPS) details, or any other geographic location system,
  • D-U-N-S (Data Universal Numbering System) Number (a unique identification number provided by Dun & Bradstreet) of the site and/or Facility Establishment Identifier (FEI), a unique identifier designated by FDA.
  • C1.3 – Manufacturing Activities – Site Master File (SMF):
  • Authorized pharmaceutical manufacturing activities at the site include the following:
    • Copy of the valid manufacturing authorization issued by the relevant Competent Authority in Appendix 1.
    • If the Competent Authority does not issue manufacturing authorization, this shall be stated in the document.
    • A brief description of manufacture, import, export, distribution, and other activities as authorized by the relevant Competent Authorities including foreign authorities with authorized dosage forms/activities, respectively; were not covered by the manufacturing authorization.
  • The type of products currently manufactured on-site (list in Appendix 2) was not covered by Appendix 1.
  • List of GMP inspections of the site within the last 5 years; including dates and name/country of the Competent Authority having performed the inspection.
  • A copy of the current GMP certificate (Appendix 3) or other relevant references shall be included, if available.
  • A brief description of Pharmaceutical manufacturing activities as licensed by the national authority.
  • This shall also include the validity period for the manufacturing license issued by the national regulatory authority.
  • C1.4 – Other Manufacturing Activity at Site.
  • This covers both pharmaceutical and non-pharmaceutical activities.
  • C1.5 – Types of Products Manufactured – Site Master File (SMF):
  • Type of actual products manufactured on the site and information about specifically toxic or hazardous substances handled, mentioning the way they are manufactured (in dedicated facilities or on a campaign basis). Product list to be attached as an annexure.
  • C1.6 – Description of the Site:(NMT 250 words/one A4 page)
  • A short description of the site shall be explained under this clause.
  • These shall include information about the location, immediate environment, area covered by the site, building facility details, size of the site, type of buildings, and their
  • C1.7 – Employment at Site:
  • The detailed information about the total number of employees engaged in the site shall be provided.
  • This shall include any part-time employees also.
  • The categorization of employees shall be done as mentioned below but not limited to:
    • Production
    • Quality Control
    • Quality Assurance
    • EHS
    • IT
    • P&A
    • HR
    • Storage & Distribution
    • Technical & Engineering services
    • Total of above
  • Note: Include employees working only part-time on a full-time equivalent basis.
  • C1.8 – Use of Out Side Technical Services:
  • Detail of use of outside scientific, analytical or other technical assistance in relation to manufacture and analysis shall be mentioned along with the name, address, telephone number, fax no, and brief outline of the activity being undertaken. (NMT 100 words/half an A4 page)
  • C2 – Quality Management System : (NMT 750 words/three A4 pages)
  • The Quality Management System (QMS) of the company includes the following:
    • Brief description of the quality management systems, and reference to the standards used for this system.
    • Provide responsibilities related to the maintaining of the quality system including senior management.
    • Provide information on activities for which the site is accredited and certified, including dates and contents of accreditations, names of accrediting.
  • The topics to be covered under these shall include but not limited to:
    • Quality Policy and Objectives
    • Introduction to Quality Division
    • Role of Corporate Quality and Corporate Compliance Division
    • Role of location Quality Assurance
    • Management responsibilities
  • Describe the elements of the QA system e.g. organizational structure, responsibilities, procedures, process, specifications, test methods, and other quality-related data collection.
  • Vendor Approval System
  • Record if standards such as ISO 9001-9004 are used by the company to assess or audit the quality assurance system within the company or by the company to assess its suppliers.
  • Scope and focus of QRM including a brief description of any activities which are performed at the corporate level, and those which are performed locally.
  • Any application of the QRM system to assess continuity of supply should be mentioned.
  • Short description of Quality by Design(QbD) and Continued Process Verification(CPV).
  • A short description of the control strategy employs process analytical technologies (PAT).
  • C2.1 – Release Procedure for Finished Products includes the following:
  • Provide a detailed description of qualification requirements, (education and work experience) of the Authorized Person(s) / Qualified Person(s) responsible for batch certification and release procedures.
  • Provide a general description of batch certification and releasing procedure.
  • Describe the role of Authorized Person/Qualified Person regarding quarantine, and release of finished products, and assessment of compliance with the Marketing Authorization.
  • Describe the arrangements and roles between Authorized Persons/Qualified Persons when several Authorized Persons/Qualified Persons are involved.
  • Provide a statement on whether the control strategy employs Process Analytical Technology (PAT) and/or Real-Time Release or Parametric Release.
  • C2.2 – Management of Suppliers and Contractors – Site Master File (SMF):
  • Provide a brief summary of the establishment/ knowledge of the supply chain and the external audit program.
  • Provide a brief description of the qualification system of contractors, manufacturers of active pharmaceutical ingredients (API), and other critical materials suppliers.
  • Describe the procedure(s) in use to ensure that products manufactured are compliant with TSE (Transmitting animal spongiform encephalopathy) guidelines.
  • Procedure(s) in use when substandard, counterfeit/ falsified products, bulk products (i.e. unpacked tablets), active pharmaceutical ingredients, or excipients, which are suspected or identified.
  • Describe when the site utilizes outside scientific, analytical, or other technical assistance, in relationship to manufacture of product and analysis.
  • Provide a listing of all contract manufacturers, and laboratories, including the addresses and contact information.
  • Provide flow charts of supply-chains for outsourced manufacturing and Quality Control activities i.e.
    • Sterilization of primary packaging material for aseptic processes,
    • The testing of starting raw materials, etc., shall be presented in Appendix 4).
  • Provide a brief overview of the responsibility-sharing between the contract giver and acceptor with respect to compliance with the Marketing Authorization.
  • C2.3 – Quality Risk Management (QRM):
  • Provide a brief description of QRM methodologies used by the manufacturing site.
  • Include the scope and focus of QRM including a brief description of any activities, which are performed at the corporate level, and activities, which are performed locally.
  • Any application of the QRM system that is utilized to assess continuity of supply shall also be included.
  • C2.4 – Product Quality Reviews:
  • Brief description of methodologies used for Product Quality Reviews.
  • C3 – Personnel – Site Master File (SMF)(NMT 500 words/two A4 pages) 
  • C3.1 – Organogram:
  • Provide an Organization chart showing the arrangements for
    • Quality management,
    • Production,
    • Quality control,
    • Engineering,
    • Storage and distribution positions/ titles to be included in Appendix 5.
    • Include senior management.
  • The number of employees engaged in quality management, production, quality control, storage, and distribution respectively shall be included in the organogram and shall be attached as an annexure.
  • C3.2 – Key Personnel (Qualifications, Experience, and Responsibilities):
  • Brief details of academic qualifications, work-related qualifications and years of relevant experience shall be furnished.
  • C3.3 – Training:
  • Brief details of the training program including induction and continuous training shall be explained along with the details as mentioned below but not limited to:
    • How training needs are identified and by whom.
    • Details of training relative to GMP requirements.
    • State the form of training e.g. in-house, external, and how practical experience is gained.
    • State how retraining needs are identified.
    • Brief details of training records kept.
  • C3.4 – Health requirement for personnel’s engaged in manufacturing activity:
  • A brief introduction to the medical check-up program shall be explained.
  • These shall include but not limited to :
    • Routine health checking of employees.
    • Pre-employment and routine medical check-up based on the nature of work.
    • System for reporting sickness or contact with sick people before working in a critical area and reporting back after illness.
    • Additional tests/checks for employees working in sterile, cytotoxic, and hormone production area.
  • C3.5 – Personal Hygiene Requirement Including Clothing:
  • A brief description of washrooms and change rooms facilities made available for the employees shall be provided.
  • C4Premises and Equipment – Site Master File (SMF):
  • C4.1 – Description of Manufacturing Areas (Man and Material Movement):
  • A simple plan or description of manufacturing areas with an indication of scale (architectural or engineering drawings are not required).
  • A site plan highlighting the production areas shall be attached as annexure.
  • If the products for different markets, i.e. for local, EU, USA, etc take place in different buildings on the site, the buildings shall be listed with destined markets identified.
  • Man and Material movement shall be explained with the aid of suitable drawings.
  • Attach the layout for each floor separately.
  • C4.2 – Nature of Construction and Finishes: (NMT 500 words/two A4 pages)
  • This shall include a description about the below mentioned but not limited to:
    • Material for the construction of the facility,
    • Flooring,
    • Electric supply,
    • Ceiling,
    • View panels,
    • Coving details,
  • Provide a simple plan of each production area along with the details of construction indicating the scale,
  • All the areas shall be properly labeled/marked.
  • C4.3 – Design Criteria for Ventilation Systems Schematic Diagram for HVAC and Dust Extraction System: (NMT 500 words/two A4 pages)
  • Give Salient features of ventilation systems.
  • More details shall be given for critical areas with potential risks of airborne contamination (schematic drawings of the systems shall be attached as annexure).
  • Classification of the rooms used for the manufacture of sterile products shall be mentioned.
  • Room classification shall be given in accordance with the grading system outlined as per GMP.
  • Schematic Diagram for HVAC and Dust Extraction System, Suitable diagrams/layouts shall be attached as annexure. (Preferably on A4 Paper only).
  • For sterile product areas, a summary of the results of the most recent qualification/requalification shall be given.
  • Following data shall be given:
    • Design criteria e.g. specification of the air supply, temperature, humidity, pressure differentials, and air changes to rate, simple pass or recirculation (percentage),
    • Filter design and efficiency,
    • Provide the details of any alarms on the ventilation system,
    • Show the PAO test and the point,
    • Give the frequency of revalidation of the system.
  • C4.4 – Special Area for handling highly toxic, hazardous, and sensitizing materials.
  • Any Special Area for handling highly toxic, hazardous, and sensitizing materials shall be highlighted in the layout.
  • C4.5 – Brief Description of Water System and Other Utilities:
  • A brief description of the water system along with schematic drawing shall be explained.
  • This shall include but not limited to:
    • The schematic drawing from the water source to final purified/ WFI water.
    • The capacity of the system (maximum quantity produced per hour).
    • Construction materials of the vessels and pipework.
    • Specification of any filters in the system.
    • If water is stored and circulated, the temperature at the point of return.
  • The specification of the water produced:
    • Chemical
    • Conductivity
    • Microbiological
  • The sampling points and frequency of sampling
  • Brief description of other relevant utilities, such as steam, compressed air, nitrogen, etc.
  • C4.6 – Planned Preventive Maintenance for Premises and Utilities: (NMT 250 words/half an A4 page)
  • The description of the planned preventative maintenance program and recording system shall be mentioned.
  • This shall include (Site Master File – SMF) but not limited to:
    • Planned preventative maintenance program.
    • Written procedures and suitable reporting forms for maintenance and servicing.
    • Whether maintenance routines that could affect product quality are clearly identified.
    • Maintenance and Servicing of the Air Handling and Water Systems.
    • “Maintenance” carried out by the manufacturer and “servicing” by an outside contractor.
  • C4.7 – Equipment: Description of Major Equipment for Production, Quality Control Laboratory & Engineering Equipment:
  • Provide a listing of major production and control laboratory equipment with critical pieces of equipment identified included in appendix 8.
  • This shall include but not limited to:
    • The material of Construction of Equipment (e.g. AISI grade 316 stainless steel for product contact equipment).
    • Are other materials used validated (e.g. polypropylene, chrome-plated brass, PVC, non-reactive plastic materials)?
  • Whether equipment is designed for ease for cleaning.
  • The general description of the equipment in production is to be furnished.
  • In the quality control laboratory, only general descriptions such as pH meters, chromatographic equipment GC, HPLC with computer systems, particle size analyzers shall be provided.
  • In microbiology use general descriptions such as incubators (temperature ranges) facilities for LAL testing, sterility testing, etc.
  • Description of GMP critical computerized system (excluding equipment specific programmable logic controllers (PLCs)).
  • C4.8 – Planned Preventive Maintenance for Equipment: (NMT 250 words/one A4 page)
  • A brief description of responsibility for maintenance and servicing of equipment,
  • whether written procedures are available, are contract services from outside agencies taken, are records maintained for type and frequency of services, details of services repairs, and modifications.
  • C4.9 – Qualification, Validation, and Calibration:(NMT 750 words/three A4 pages)
  • This shall include but not limited to:
    • Brief description of the company’s general policy for qualification and validation.
    • Briefly describe the re-validation policy.
    • Areas covered under the validation program.
    • The system for the release for sale or supply of development and validation batches.
    • The arrangements for computer validation, including software validation.
    • Equipment/Instrument calibration policy and records kept.
  • C4.10 – Cleaning and Sanitation – Site Master File (SMF): (NMT 250 words/Half A4 page)
  • This shall include but not limited to :
  • Written specifications and procedures for cleaning, cleaning agents and their concentration, method of cleaning, and the frequency(i.e. Manual cleaning, automatic clean-in-place, etc).
  • Change of cleaning agents from time to time.
  • Validation of Cleaning Procedures.
  • Method of evaluating the effectiveness of cleaning.
  • Cleaning methods monitored routinely by chemical and/or microbiological methods.
  • The cleaning methods (and their frequency) for the water supply system, air handling system and dust extraction system.
  • C4.11 – GMP critical computerized systems:
  • Description of GMP critical computerized systems (excluding equipment specific Programmable Logic Controllers (PLCs)).
  • C5 – Documentation – Site Master File (SMF): (NMT 500 words/two A4 pages)
  • C5.1 – Preparation, revision, and distribution of necessary documentation for manufacturing:
  • Description of the documentation system utilized at the manufacturing site (i.e. electronic, manual).
  • When documents and records are stored or archived off-site (including pharmacovigilance data, when applicable):
  • List types of documents/records; Name and address of storage site, and an estimate of document retrieval time required from the off-site archive.
  • This shall include but not limited to:
    • Documents such as Batch Manufacturing and Packing Records (BMR & BPR),
    • SOPs,
    • Specification,
    • Analytical Test Procedures,
    • VMPs,
    • Scale Up reports,
    • Validation protocol Reports,
    • Technology Transfer documents,
    • Qualification documents,
    • Training material and records,
    • Analytical Worksheets registers formats etc.
  • Responsibility for the preparation revision and distribution of documents.
  • Storage and handling of Master Documents.
  • Brief Description for Documentation on:
  • Product/Process Specifications
  • Raw material specifications
  • Packaging component specifications
  • Standard process instructions including packaging
  • Batch records including packaging
  • Product quality review/Annual product review
  • Analytical methods
  • QA release procedures
  • Document Control
  • Retention Period for Documents
  • Arrangements for any Electronic records / Backups
  • If documents and records are stored or archived off-site, List of types of documents/records; Name and address of storage site, and an estimate of the time required retrieving documents from the off-site archive.
  • C5.2 – Other Documentation Related to Product Quality – Site Master File (SMF):
  • This shall include but not limited to:
    • Equipment specifications
    • Specifications for disposables i.e. cleaning materials
    • Standard operating procedure
    • Quality Control Procedures
    • Training procedures
    • Computer program specifications
    • Documentation control of process deviations
    • Calibration and test documents
    • Validation documents
    • Reconciliation of bathes of raw materials, bulk product, major packing Components i.e. product-contact and printed material.
  • C5.3 – Additional Documentation :
    • List and briefly explain the use of any additional standard documentation used routinely.
  • C6 – Production – Site Master File (SMF):
  • Type of Products: In this section of the site master file (SMF), provide a reference to Appendix 1 or 2.
  • The type of products manufactured includes the following:
    • List of all dosage forms of both human and veterinary products, which are manufactured on site.
    • List of all dosage forms for investigational medicinal products (IMP) manufactured for any clinical trials on-site, and when different from the commercial manufacturing, information of production areas and personnel.
  • C6.1 – Brief description of production operations using, wherever possible, flow sheets and charts specifying important parameters but not limited to:
    • Description of Manufacturing Operations.
    • The operations capable of being carried out at the site with the existing facilities and specify the categories of medicinal products.
    • If cytotoxic or hormone or radio-active substances are handled give details of the products.
    • Explain the production operations using flow charts.
  • C6.2 – Arrangements for the handling of starting materials, packaging materials, bulk, and finished products, including sampling, quarantine, release, and storage.
  • Identification of supplier’s lot number with the company’s lot number.
  • Sampling plans.
  • Status labeling e.g. by using labels or by computer.
  • Issue of materials to manufacture and package.
  • The control of weighing.
  • Checking methods.
  • Identification of materials to be used for manufacturing.
  • Packaging shall include but not limited to:
    • Release of bulk, semi-finished products, packing materials.
    • Confirmation of identity and line clearance checks.
    • In-process checks.
    • Records of key parameters of manufacturing.
    • Quarantine and release of finished products; compliance with the Marketing Authorization.
    • The role of the Authorized Person(s) and/or Qualified Person(s).
  • C6.3 – Brief description of arrangements for the handling of rejected materials and products:
    • Labeling of rejected materials.
    • Storage in Secure and separate areas.
    • Describe arrangements for sentencing the materials and their disposal.
    • Maintenance of destruction record
  • C6.4 – Process Validation:
  • Brief description of the general policy for process validation.
  • C6.5 – Reprocessing or Reworking:
  • Describe the policy for reprocessing or reworking.
  • C7 – Quality Control – Site Master File (SMF):
  • C7.1 – Brief description of the Quality Control activities carried out at the manufacturing site in terms of physical, chemical, and microbiological and biological testing, and the procedures for the release of finished products.
  • Activities of the Quality Control Department shall include but not limited to:
    • Briefly describe the activities of analytical testing, packaging, component testing, and microbiological testing.
    • If the review of batch documentation and release of final documentation takes place in QC.
    • Outline the involvement in the arrangements for the preparation, revision, and distribution of documents in particular those for specific test methods and release criteria if not mentioned elsewhere.
    • Packaging Material and Raw material Testing.
    • In-process and Finished Product Testing.
    • Stability Testing.
    • Microbiological Testing.
    • Release System.
  • C8 – Distribution, Product Defect, Complaint, and Product Recall:
  • C8.1 – Description of Storage and Distribution Practices  – Site Master File (SMF):
  • Storage and Distribution shall include but not limited to:
    • Description of Storage and Distribution Practices
    • Details of warehouse security
    • Environmental control
    • Refrigerated storage
    • How are the materials stored e.g. pallet racking?
    • How is the status of products controlled e.g. by computer, by the label?
    • Isolation of reject material securely
    • Methods of distribution
    • Dispatch order system to ensure first expire/first out and identification of the lot number
    • Records of Distribution
    • Types (wholesale license holders, manufacturing license holders, etc) and locations (EU/EEA, USA, etc) of the companies to which the products are shipped from the site.
  • Brief description of the system to ensure appropriate environmental conditions during transit, e.g. temperature monitoring/control.
  • Brief that retained records permit full batch traceability from the factory to the customer, in terms of the date of sale, customer details, and quantity dispatched.
  • Arrangements for product distribution and methods by which product traceability is maintained.
  • Provide a description of the procedures or measures taken to prevent manufacturers’ products to fall in the illegal supply chain.
  • C8.2- Handling of Product Defects, Complaints, and Product Recall:
  • A brief description for the flow of complaints shall be explained to address the following but not limited to:
    • Logging of complaints
    • Classifying the complaints
    • Investigating complaints
    • Preparation and review of investigation reports
    • For how long are complaints records kept
  • Product Recalls: A brief description about the product recall system shall be explained which shall include but not limited to:
  • Responsible persons for product recalls
  • Details of written procedure which describes the sequence of actions to be followed including:
    • Retrieval of distribution data;
    • Notification to customers;
    • Receipt/segregation/inspection of returned product;
    • Investigation/reporting of the cause;
    • Reporting corrective action;
    • The person who notifies the Competent Authority of complaints and recall;
    • The Competent Authority involved in complaints and the decision to recall;
    • Effectiveness of recalls at below wholesale level;
    • List of product recalled over the last two years;
    • If none has been recalled, record-None.
  • C9 – Self Inspection – Site Master File (SMF):
  • C9.1 – Description of Self Inspection Program:
  • A short description of the self-inspection system utilized with focus on criteria used for selection of the areas to be covered during planned inspections, practical arrangements, evaluation of self-inspection, and follow-up actives.
  • Documented procedures and records for the self-inspection system and the follow-up actions.
  • C9.2 – Regulatory Inspection – Site Master File (SMF):
  • A brief description of inspections conducted by national authorities in the last five years.
  • A brief description of inspections conducted by international regulatory authorities in the last five years, including date and name/country of the competent authorities.
  • A copy of the current GMP certificates shall be attached.
  • Document and data control for Site Master File (SMF) :
  • Appropriate information shall be supplied in form of Annexure and the reference of the same shall be made in the point.
  • All the pages of the Annexure attached shall be numbered separately, i.e. they shall not be in continuation with the page numbering system of the Site Master File (SMF).
  • The Site Master File (SMF) shall have a Revision history as below,
Revision History
SMF No.:Change Control No.:Effective Date
Changes :
  • The Revision history shall be page numbered separately.
  • The Revision history shall serve the purpose of Site Master File (SMF) reviews starting from the first revision 00 itself.
  • The review of the Site Master File (SMF) shall be done within ± 30 days from the date of the Next Review.
  • Any revision to be done to the Site Master File (SMF) in the existing year shall be in the forms of Amendments.
  • The Obsolete copy of the Site Master File (SMF) shall be stamped as “OBSOLETE”, stored and destroyed as per document control SOP.
  • If Revision is not required after review of the Site Master File (SMF), re-certify SMF for the validity of continuing usage as per respective SOP.
  • QA shall issue a controlled copy of the site master file (SMF) to Factory Head for reference.
  • Copy of Site Master File (SMF) required by any Regulatory / Any other Agency shall be forwarded through Head – Quality/ or designee by putting the stamp of UNCONTROLLED COPY.
  • Uncontrolled Copy Issuance record of site master file (SMF) shall be maintained as per Annexure-4.

7.0   ANNEXURES – SITE MASTER FILE (SMF):

Annexure 1: Site Master File (SMF) WorkFlow.

Site Master File (SMF)-Content

Annexure 2: List of Annexure.

Sr. No.Annexures NumberAnnexures DetailsTotal No. of PagesQA Head Sign/Date

Annexure 3: Index for Amendment.

Sr. NoSection No. of Site Master File (SMF)Amendment No.Effective DateTotal No. of PagesQA Head Sign /Date

Annexure 4: Uncontrolled SMF Issuance Format.

Sr.No.Site Master File (SMF) No.Issued ToIssued By/ DateRemarks

WARNING LETTER

Pfizer Healthcare India Private Limited

Warning Letter 2020

The U.S. Food and Drug Administration (FDA) inspected your drug manufacturing facility, Pfizer Healthcare India Private Limited, FEI 3008316085, at Plots 116-117-118-119-111-123 (part), Jawaharlal Nehru Pharma City, Parawada, Visakhapatnam, Andhra Pradesh, India, from August 29 to September 6, 2019.

This warning letter summarizes significant violations of current good manufacturing practice (CGMP) regulations for finished pharmaceuticals. See Title 21 Code of Federal Regulations (CFR), parts 210 and 211 (21 CFR parts 210 and 211).

Because your methods, facilities, or controls for manufacturing, processing, packing, or holding do not conform to CGMP, your drug products are adulterated within the meaning of section 501(a)(2)(B) of the Federal Food, Drug, and Cosmetic Act (FD&C Act), 21 U.S.C. 351(a)(2)(B).

We reviewed your September 27, 2019, response to our Form FDA 483 in detail and acknowledge receipt of your subsequent correspondence.

During our inspection, our investigator observed specific violations including, but not limited to, the following.

Your firm failed to thoroughly investigate any unexplained discrepancy or failure of a batch or any of its components to meet any of its specifications, whether or not the batch has already been distributed (21 CFR 211.192).

Your facility manufactures (b)(4) injectable products. Your firm failed to conduct adequate investigations, including timely implementation of effective corrective action and preventive action (CAPA) plans.

Failed Sterility Testing

You did not adequately investigate root causes and implement CAPA to address deficiencies regarding your sterility testing (b)(4). For example, in February 2019, you investigated the sterility failure of (b)(4) injection batch (b)(4). You determined the most probable root cause of this sterility failure was the “lack of robust (b)(4) integrity testing and possible non-integral drug product vials.” You also stated that the source of the microbial contamination may have been a faulty (b)(4). This batch was rejected. However, you continued to use the same (b)(4) and performed sterility testing for a substantial number of additional batches before you made corrections, including replacing the suspect (b)(4).

Your response stated that you will implement automated (b)(4) integrity testing, which is planned for July 2020. Previously, you lacked an automated integrity test, and instead relied on a visual check that was insufficient on its own to reliably detect (b)(4).

You also indicated that, effective January 2020, you would inspect sterility test samples for integrity before introduction to the sterility (b)(4).

The timeliness of the CAPA to resolve these significant root causes was insufficient. Your response did not adequately address the delay in CAPA implementation. Your response also indicated that you had made revisions to the investigation and that these revisions were completed on September 27, 2019. However, your response lacked the revised investigation and the status of your CAPA progress.

Environmental Monitoring Program

You did not adequately investigate serious deficiencies in microbiology laboratory conditions and practices. Among the deficiencies were excessive occurrences of negative control plate contamination, high levels of contamination in environmental monitoring (EM) samples of the sterility test (b)(4), and disregarded EM data because of delayed plate readings. More specifically:

• You did not thoroughly investigate negative environmental trends observed in the (b)(4) used to support sterility testing. Repeated recoveries were observed in the (b)(4), including excessively high levels (e.g., (b)(4), too-numerous-to-count (TNTC) CFU/m3), in some cases, over a three month period.

• You did not adequately investigate numerous instances over a one year period of microbial growth on negative control plates. These plates were used to support the EM program in both your production and laboratory areas.

• You invalidated microbial results without adequate scientific justification. Between September 26 and December 23, 2018, your biological quality laboratory allowed EM and testing plates used for monitoring your facility to be incubated beyond the days established in procedures. You attributed this recurring issue to a lack of qualified personnel. These plates included but are not limited to EM of the (b)(4), negative control plates, and product bioburden analysis. The testing results were repeatedly invalidated as the counts were considered unreliable, although the risks posed by the potentially valid contamination findings and related impact were not sufficiently addressed. Approximately (b)(4) batches were made during this period.

Your investigation into the extended incubation of plates indicates that they were being read on a “(b)(4)” basis. While you indicate you were reading plates (b)(4), you lacked documentation of earlier readings performed before the extended incubation times. The investigation also discusses the commingling of media plates in the same bag that were overgrown to the point that one plate may have contaminated another plate.

Laboratory data accuracy deficiencies were also cited in our September 2018 inspection.

In your response, you indicated there are ongoing investigations to address the root causes of the recurring growth on negative control plates. You indicated that you have taken initial measures such as adding a new media vendor and improving incubator maintenance.

Regarding the significant adverse environmental monitoring trends in your sterility testing (b)(4), your response stated that no additional EM excursions had occurred in your (b)(4) since you initiated your CAPA. The CAPA steps included addition of a (b)(4) to the (b)(4), better disinfection of supplies, slower (b)(4) movements, and retraining.

You also stated that you are improving overall laboratory capabilities and investigations systems.

However, your response did not fully address how deficient laboratory controls, inadequate investigations, and delays in implementing CAPA compromised your firm’s microbiological control program.

In response to this letter, provide the following:

• A comprehensive assessment of your overall system for investigating deviations, discrepancies, complaints, out-of-limit results, out-of-specification results, and failures. Provide a detailed action plan to remediate this system. Your action plan should include, but not be limited to, significant improvements in investigation competencies, scope determination, root cause evaluation, CAPA effectiveness, quality assurance oversight, and written procedures. Address how your firm will ensure all phases of investigations are appropriately conducted.

• An assessment and remediation plan for your CAPA program. Provide a report that evaluates whether your firm effectively conducts root cause analysis, ensures CAPA effectiveness, regularly reviews investigations trends, implements improvements to the CAPA program when needed, ensures appropriate quality assurance decision rights, and is fully supported by executive management.

• A complete assessment of documentation systems used throughout your manufacturing and laboratory operations to determine where documentation practices are insufficient. Include a detailed CAPA plan that comprehensively remediates your firm’s documentation practices to ensure you retain attributable, legible, complete, original, accurate, contemporaneous records throughout your operation.

• A comprehensive, independent assessment of your laboratory practices, procedures, methods, equipment, documentation, analyst competencies, and resources. Regarding the latter, the assessment should address the adequacy of qualified staff needed to produce reliable results within appropriate timelines as well as your practices for managing the tracking of samples and timely reading of test results. Based on this review, provide a detailed plan to remediate and evaluate the effectiveness of your laboratory system.

• Your revised investigations regarding the sterility failure and the loss of environment control in the sterility testing (b)(4). The updated investigations should include, but not be limited to:
    o A final summary of all factors that may have compromised (b)(4) integrity, corrective actions, and your re-qualification results.
    o Further explanation of the potential product container-closure integrity root cause that appears to have been ruled out as a cause of the sterility failure. Provide a detailed summary of the defect and deviation rates that are relevant to container-closure integrity from your batch records over the last two years. In addition, explain the atypical manufacturing conditions that could impact container-closure integrity.

• A summary of your completed negative control plate investigations that were ongoing at the close of the inspection.

• Your response concerning extended incubation of media plates leading to the invalidation of EM results. Include a summary worksheet that documents the date that each plate was read, the date each plate was scheduled to be read, and the difference in the number of days between the actual date and the scheduled date. Clarify if you read and document microbial plates samples more than once during the incubation period and whether you document the results each time. Also provide your investigation for the TNTC result documented in PR#2466588. Include the methods used for bioburden, dilutions, and counting of microbes.

Data Integrity Remediation

Your quality system does not adequately ensure the accuracy and integrity of data to support the safety, effectiveness, and quality of the drugs you manufacture. For guidance on establishing and following CGMP compliant data integrity practices, see FDA’s guidance documents Data Integrity and Compliance With Drug CGMP at https://www.fda.gov/downloads/DRUGS/GuidanceComplianceRegulatoryInformation/Guidances/UCM495891.pdf and Questions and Answers on Current Good Manufacturing Practices—Laboratory Controls at https://www.fda.gov/DRUGS/Guidances-Drugs/Questions-And-Answers-Current-Good-Manufacturing-Practices-Laboratory-Controls#17.

We acknowledge that you engaged a consultant to audit your operation and assist in meeting FDA requirements.

In response to this letter, provide the following:

• A comprehensive investigation into the extent of the inaccuracies in data records and reporting including results of the data review for drugs distributed to the United States. Include a detailed description of the scope and root causes of your data integrity lapses.

• A current risk assessment of the potential effects of the observed failures on the quality of your drugs. Your assessment should include analyses of the risks to patients caused by the release of drugs affected by a lapse of data integrity and analyses of the risks posed by ongoing operations.

• A management strategy for your firm that includes the details of your global corrective action and preventive action plan. The detailed corrective action plan should describe how you intend to ensure the reliability and completeness of all data generated by your firm including microbiological and analytical data, manufacturing records, and all data submitted to FDA.

Conclusion

The violations cited in this letter are not intended to be an all-inclusive list of violations that exist at your facility. You are responsible for investigating and determining the causes of these violations and for preventing their recurrence or the occurrence of other violations.

If you are considering an action that is likely to lead to a disruption in the supply of drugs produced at your facility, FDA requests that you contact CDER’s Drug Shortages Staff immediately, at [email protected], so that FDA can work with you on the most effective way to bring your operations into compliance with the law. Contacting the Drug Shortages Staff also allows you to meet any obligations you may have to report discontinuances or interruptions in your drug manufacture under 21 U.S.C. 356C(b). This also allows FDA to consider, as soon as possible, what actions, if any, may be needed to avoid shortages and protect the health of patients who depend on your products.

Until you correct all violations completely and we confirm your compliance with CGMP, FDA may withhold approval of any new drug applications or supplements listing your firm as a drug manufacturer.

Failure to correct these violations may also result in the FDA refusing admission of articles manufactured at Pfizer Healthcare India Private Limited, FEI 3008316085, at Plots 116-117-118-119-111-123 (part), into the United States under section 801(a)(3) of the FD&C Act, 21 U.S.C. 381(a)(3). Articles under this authority may be subject to refusal of admission, in that the methods and controls used in their manufacture do not appear to conform to CGMP within the meaning of section 501(a)(2)(B) of the FD&C Act, 21 U.S.C. 351(a)(2)(B).

GUIDE TO INSPECTIONS OF HIGH PURITY WATER SYSTEMS


GUIDE TO INSPECTIONS OF HIGH PURITY WATER SYSTEMS

Note: This document is reference material for investigators and other FDA personnel. The document does not bind FDA, and does no confer any rights, privileges, benefits, or immunities for or on any person(s).

This guide discusses, primarily from a microbiological aspect, the review and evaluation of high purity water systems that are used for the manufacture of drug products and drug substances. It also includes a review of the design of the various types of systems and some of the problems that have been associated with these systems. As with other guides, it is not all-inclusive, but provides background and guidance for the review and evaluation of high purity water systems. The Guide To Inspections of Microbiological Pharmaceutical Quality Control Laboratories (May, 1993) provides additional guidance.

I. SYSTEM DESIGN

One of the basic considerations in the design of a system is the type of product that is to be manufactured. For parenteral products where there is a concern for pyrogens, it is expected that Water for Injection will be used. This applies to the formulation of products, as well as to the final washing of components and equipment used in their manufacture. Distillation and Reverse Osmosis (RO) filtration are the only acceptable methods listed in the USP for producing Water for Injection. However, in the bulk Pharmaceutical and Biotechnology industries and some foreign companies, Ultra Filtration (UF) is employed to minimize endotoxins in those drug substances that are administered parenterally.

For some ophthalmic products, such as the ophthalmic irrigating solution, and some inhalation products, such as Sterile Water for Inhalation, where there are pyrogen specifications, it is expected that Water for Injection be used in their formulation. However, for most inhalation and ophthalmic products, purified water is used in their formulation. This also applies to topicals, cosmetics and oral products.

Another design consideration is the temperature of the system. It is recognized that hot (65 – 80oC) systems are self sanitizing. While the cost of other systems may be less expensive for a company, the cost of maintenance, testing and potential problems may be greater than the cost of energy saved. Whether a system is circulating or one-way is also an important design consideration. Obviously, water in constant motion is less liable to have high levels of contaminant. A one-way water system is basically a “dead-leg”.

Finally, and possibly the most important consideration, is the risk assessment or level of quality that is desired. It should be recognized that different products require different quality waters. Parenterals require very pure water with no endotoxins. Topical and oral products require less pure water and do not have a requirement for endotoxins. Even with topical and oral products there are factors that dictate different qualities for water. For example, preservatives in antacids are marginally effective, so more stringent microbial limits have to be set. The quality control department should assess each product manufactured with the water from their system and determine the microbial action limits based on the most microbial sensitive product. In lieu of stringent water action limits in the system the manufacturer can add a microbial reduction step in the manufacturing process for the sensitive drug product(s).

II. SYSTEM VALIDATION

A basic reference used for the validation of high purity water systems is the Parenteral Drug Association Technical Report No. 4 titled, “Design Concepts for the Validation of a Water for Injection System.”

The introduction provides guidance and states that, “Validation often involves the use of an appropriate challenge. In this situation, it would be undesirable to introduce microorganisms into an on-line system; therefore, reliance is placed on periodic testing for microbiological quality and on the installation of monitoring equipment at specific checkpoints to ensure that the total system is operating properly and continuously fulfilling its intended function.”

In the review of a validation report, or in the validation of a high purity water system, there are several aspects that should be considered. Documentation should include a description of the system along with a print. The drawing needs to show all equipment in the system from the water feed to points of use. It should also show all sampling points and their designations. If a system has no print, it is usually considered an objectionable condition. The thinking is if there is no print, then how can the system be validated? How can a quality control manager or microbiologist know where to sample? In those facilities observed without updated prints, serious problems were identified in these systems. The print should be compared to the actual system annually to insure its accuracy, to detect unreported changes and confirm reported changes to the system.

After all the equipment and piping has been verified as installed correctly and working as specified, the initial phase of the water system validation can begin. During this phase the operational parameters and the cleaning/ sanitization procedures and frequencies will be developed. Sampling should be daily after each step in the purification process and at each point of use for two to four weeks. The sampling procedure for point of use sampling should reflect how the water is to be drawn e.g. if a hose is usually attached the sample should be taken at the end of the hose. If the SOP calls for the line to be flushed before use of the water from that point, then the sample is taken after the flush. At the end of the two to four week time period the firm should have developed its SOPs for operation of the water system.

The second phase of the system validation is to demonstrate that the system will consistently produce the desired water quality when operated in conformance with the SOPs. The sampling is performed as in the initial phase and for the same time period. At the end of this phase the data should demonstrate that the system will consistently produce the desired quality of water.

The third phase of validation is designed to demonstrate that when the water system is operated in accordance with the SOPs over a long period of time it will consistently produce water of the desired quality. Any variations in the quality of the feedwater that could affect the operation and ultimately the water quality will be picked up during this phase of the validation. Sampling is performed according to routine procedures and frequencies. For Water for Injection systems the samples should be taken daily from a minimum of one point of use, with all points of use tested weekly. The validation of the water system is completed when the firm has a full years worth of data.

While the above validation scheme is not the only way a system can be validated, it contains the necessary elements for validation of a water system. First, there must be data to support the SOPs. Second, there must be data demonstrating that the SOPs are valid and that the system is capable of consistently producing water that meets the desired specifications. Finally, there must be data to demonstrate that seasonal variations in the feedwater do not adversely affect the operation of the system or the water quality.

The last part of the validation is the compilation of the data, with any conclusions into the final report. The final validation report must be signed by the appropriate people responsible for operation and quality assurance of the water system.

A typical problem that occurs is the failure of operating procedures to preclude contamination of the system with non-sterile air remaining in a pipe after drainage. In a system illustrated as in Figure 1, (below) a typical problem occurs when a washer or hose connection is flushed and then drained at the end of the operation. After draining, this valve (the second off of the system) is closed. If on the next day or start-up of the operation the primary valve off of the circulating system is opened, then the non-sterile air remaining in the pipe after drainage would contaminate the system. The solution is to pro-vide for operational procedures that provide for opening the secondary valve before the primary valve to flush the pipe prior to use.

figure 1 Circuling loop

Another major consideration in the validation of high purity water systems is the acceptance criteria. Consistent results throughout the system over a period of time constitute the primary element.

III. MICROBIAL LIMITS

Water For Injection Systems

Regarding microbiological results, for Water For Injection, it is expected that they be essentially sterile. Since sampling frequently is performed in non-sterile areas and is not truly aseptic, occasional low level counts due to sampling errors may occur. Agency policy, is that less than 10 CFU/100ml is an acceptable action limit. None of the limits for water are pass/fail limits. All limits are action limits. When action limits are exceeded the firm must investigate the cause of the problem, take action to correct the problem and assess the impact of the microbial contamination on products manufactured with the water and document the results of their investigation.

With regard to sample size, 100 – 300 mL is preferred when sampling Water for Injection systems. Sample volumes less than 100 mL are unacceptable.

The real concern in WFI is endotoxins. Because WFI can pass the LAL endotoxin test and still fail the above microbial action limit, it is important to monitor WFI systems for both endotoxins and microorganisms.

Purified Water Systems

For purified water systems, microbiological specifications are not as clear. USP XXII specifications, that it complies with federal Environmental Protection Agency regulations for drinking water, are recognized as being minimal specifications. There have been attempts by some to establish meaningful microbiological specifications for purified water. The CFTA proposed a specification of not more than 500 organisms per ml. The USP XXII has an action guideline of not greater than 100 organisms per ml. Although microbiological specifications have been discussed, none (other than EPA standards) have been established. Agency policy is that any action limit over 100 CFU/mL for a purified water system is unacceptable.

The purpose of establishing any action limit or level is to assure that the water system is under control. Any action limit established will depend upon the overall purified water system and further processing of the finished product and its use. For example, purified water used to manufacture drug products by cold processing should be free of objectionable organisms. We have defined “objectionable organisms” as any organisms that can cause infections when the drug product is used as directed or any organism capable of growth in the drug product. As pointed out in the Guide to Inspections of Microbiological Pharmaceutical Quality Control Laboratories, the specific contaminant, rather than the number is generally more significant.

Organisms exist in a water system either as free floating in the water or attached to the walls of the pipes and tanks. When they are attached to the walls they are known as biofilm, which continuously slough off organisms. Thus, contamination is not uniformly distributed in a system and the sample may not be representative of the type and level of contamination. A count of 10 CFU/mL in one sample and 100 or even 1000 CFU/mL in a subsequent sample would not be unrealistic.

Thus, in establishing the level of contamination allowed in a high purity water system used in the manufacture of a non-sterile product requires an understanding of the use of the product, the formulation (preservative system) and manufacturing process. For example, antacids, which do not have an effective preservative system, require an action limit below the 100 CFU/mL maximum.

The USP gives some guidance in their monograph on Microbiological Attributes of Non-Sterile Products. It points out that, “The significance of microorganisms in non-sterile pharmaceutical products should be evaluated in terms of the use of the product, the nature of the product, and the potential harm to the user.” Thus, not just the indicator organisms listed in some of the specific monographs present problems. It is up to each manufacturer to evaluate their product, the way it is manufactured, and establish am acceptable action level of contamination, not to exceed the maximum, for the water system, based on the highest risk product manufactured with the water.

IV. WATER FOR INJECTION SYSTEMS

In the review and evaluation of Water For Injection systems, there are several concerns.

Pretreatment of feedwater is recommended by most manufacturers of distillation equipment and is definitely required for RO units. The incoming feedwater quality may fluctuate during the life of the system depending upon seasonal variations and other external factors beyond the control of the pharmaceutical facility. For example, in the spring (at least in the N.E.), increases in gram negative organisms have been known. Also, new construction or fires can cause a depletion of water stores in old mains which can cause an influx of heavily contaminated water of a different flora.

A water system should be designed to operate within these anticipated extremes. Obviously, the only way to know the extremes is to periodically monitor feedwater. If the feedwater is from a municipal water system, reports from the municipality testing can be used in lieu of in-house testing.

V. STILL

Figures 3-5 represent a typical basic diagram of a WFI system. Most of the new systems now use multi-effect stills. In some of the facilities, there has been evidence of endotoxin contamination. In one system this occurred, due to malfunction of the feedwater valve and level control in the still which resulted in droplets of feedwater being carried over in the distillate.

In another system with endotoxin problems, it was noted that there was approximately 50 liters of WFI in the condenser at the start-up. Since this water could lie in the condenser for up to several days (i.e., over the weekend), it was believed that this was the reason for unacceptable levels of endotoxins.

More common, however, is the failure to adequately treat feedwater to reduce levels of endotoxins. Many of the still fabricators will only guarantee a 2.5 log to 3 log reduction in the endotoxin content. Therefore, it is not surprising that in systems where the feedwater occasionally spikes to 250 EU/ml, unacceptable levels of endotoxins may occasionally appear in the distillate (WFI). For example, recently three new stills, including two multi-effect, were found to be periodically yielding WFI with levels greater than .25 EU/ml. Pretreatment systems for the stills included only deionization systems with no UF, RO or distillation. Unless a firm has a satisfactory pretreatment system, it would be extremely difficult for them to demonstrate that the system is validated.

The above examples of problems with distillation units used to produce WFI, point to problems with maintenance of the equipment or improper operation of the system indicating that the system has not been properly validated or that the initial validation is no longer valid. If you see these types of problems you should look very closely at the system design, any changes that have been made to the system, the validation report and the routine test data to determine if the system is operating in a state of control.

Typically, conductivity meters are used on water systems to monitor chemical quality and have no meaning regarding microbiological quality.

Figures 3-5 also show petcocks or small sampling ports between each piece of equipment, such as after the still and before the holding tank. These are in the system to isolate major pieces of equipment. This is necessary for the qualification of the equipment and for the investigation of any problems which might occur.

VI. HEAT EXCHANGERS

One principal component of the still is the heat exchanger. Because of the similar ionic quality of distilled and deionized water, conductivity meters cannot be used to monitor microbiological quality. Positive pressure such as in vapor compression or double tubesheet design should be employed to prevent possible feedwater to distillate contamination in a leaky heat exchanger.

An FDA Inspectors Technical Guide with the subject of “Heat Exchangers to Avoid Contamination” discusses the design and potential problems associated with heat exchangers. The guide points out that there are two methods for preventing contamination by leakage. One is to provide gauges to constantly monitor pressure differentials to ensure that the higher pressure is always on the clean fluid side. The other is to utilize the double-tubesheet type of heat exchanger.

In some systems, heat exchangers are utilized to cool water at use points. For the most part, cooling water is not circulated through them when not in use. In a few situations, pinholes formed in the tubing after they were drained (on the cooling water side) and not in use. It was determined that a small amount of moisture remaining in the tubes when combined with air caused a corrosion of the stainless steel tubes on the cooling water side. Thus, it is recommended that when not in use, heat exchangers not be drained of the cooling water.

VII. HOLDING TANK

In hot systems, temperature is usually maintained by applying heat to a jacketed holding tank or by placing a heat exchanger in the line prior to an insulated holding tank.

The one component of the holding tank that generates the most discussion is the vent filter. It is expected that there be some program for integrity testing this filter to assure that it is intact. Typically, filters are now jacketed to prevent condensate or water from blocking the hydrophobic vent filter. If this occurs (the vent filter becomes blocked), possibly either the filter will rupture or the tank will collapse. There are methods for integrity testing of vent filters in place.

It is expected, therefore, that the vent filter be located in a position on the holding tank where it is readily accessible.

Just because a WFI system is relatively new and distillation is employed, it is not problem-free. In an inspection of a manufacturer of parenterals, a system fabricated in 1984 was observed. Refer to Figure 6. While the system may appear somewhat complex on the initial review, it was found to be relatively simple. Figure 7 is a schematic of the system. The observations at the conclusion of the inspection of this manufacturer included, “Operational procedures for the Water For Injection system failed to provide for periodic complete flushing or draining. The system was also open to the atmosphere and room environment. Compounding equipment consisted of non-sealed, open tanks with lids. The Water for Injection holding tank was also not sealed and was never sampled for endotoxins.” Because of these and other comments, the firm recalled several products and discontinued operations.

VIII. PUMPS

Pumps burn out and parts wear. Also, if pumps are static and not continuously in operation, their reservoir can be a static area where water will lie. For example, in an inspection, it was noted that a firm had to install a drain from the low point in a pump housing. Pseudomonas sp. contamination was periodically found in their water system which was attributed in part to a pump which only periodically is operational.

IX. PIPING

Piping in WFI systems usually consist of a high polished stainless steel. In a few cases, manufacturers have begun to utilize PVDF (polyvinylidene fluoride) piping. It is purported that this piping can tolerate heat with no extractables being leached. A major problem with PVDF tubing is that it requires considerable support. When this tubing is heated, it tends to sag and may stress the weld (fusion) connection and result in leakage. Additionally, initially at least, fluoride levels are high. This piping is of benefit in product delivery systems where low level metal contamination may accelerate the degradation of drug product, such as in the Biotech industry.

One common problem with piping is that of “dead-legs”. The proposed LVP Regulations defined dead-legs as not having an unused portion greater in length than six diameters of the unused pipe measured from the axis of the pipe in use. It should be pointed out that this was developed for hot 75 – 80o circulating systems. With colder systems (65 – 75oC), any drops or unused portion of any length of piping has the potential for the formation of a biofilm and should be eliminated if possible or have special sanitizing procedures. There should be n o threaded fittings in a pharmaceutical water system. All pipe joints must utilize sanitary fittings or be butt welded. Sanitary fittings will usually be used where the piping meets valves, tanks and other equipment that must be removed for maintenance or replacement. Therefore, the firm’s procedures for sanitization, as well as the actual piping, should be reviewed and evaluated during the inspection.

X. REVERSE OSMOSIS

Another acceptable method for manufacturing Water for Injection is Reverse Osmosis (RO). However, because these systems are cold, and because RO filters are not absolute, microbiological contamination is not unusual. Figure 8 shows a system that was in use several years ago. There are five RO units in this system which are in parallel. Since RO filters are not absolute, the filter manufacturers recommend that at least two be in series. The drawing also illustrates an Ultraviolet (UV) light in the system downstream from the RO units. The light was needed to control microbiological contamination.

Also in this system were ball valves. These valves are not considered sanitary valves since the center of the valve can have water in it when the valve is closed. This is a stagnant pool of water that can harbor microorganisms and provide a starting point for a biofilm.

As an additional comment on RO systems, with the recognition of microbiological problems, some manufacturers have installed heat exchangers immediately after the RO filters to heat the water to 75 – 80oC to minimize microbiological contamination.

With the development of biotechnology products, many small companies are utilizing RO and UF systems to produce high purity water. For example, Figure 9 illustrates a wall mounted system that is fed by a single pass RO unit.

As illustrated, most of these systems employ PVC or some type of plastic tubing. Because the systems are typically cold, the many joints in the system are subject to contamination. Another potential problem with PVC tubing is extractables. Looking at the WFI from a system to assure that it meets USP requirements without some assurance that there are no extractables would not be acceptable.

The systems also contain 0.2 micron point of use filters which can mask the level of microbiological contamination in the system. While it is recognized that endotoxins are the primary concern in such a system, a filter will reduce microbiological contamination, but not necessarily endotoxin contamination. If filters are used in a water system there should be a stated purpose for the filter, i.e., particulate removal or microbial reduction, and an SOP stating the frequency with which the filter is to be changed which is based on data generated during the validation of the system.

As previously discussed, because of the volume of water actually tested (.1ml for endotoxins vs. 100ml for WFI), the microbiological test offers a good index of the level of contamination in a system. Therefore, unless the water is sampled prior to the final 0.2 micron filter, microbiological testing will have little meaning.

At a reinspection of this facility, it was noted that they corrected the deficient water system with a circulating stainless steel piping system that was fed by four RO units in series. Because this manufacturer did not have a need for a large amount of water (the total system capacity was about 30 gallons), they attempted to let the system sit for approximately one day. Figure 9 shows that at zero time (at 9 AM on 3/10), there were no detectable levels of microorganisms and of endotoxins. After one day, this static non-circulating system was found to be contaminated. The four consecutive one hour samples also illustrate the variability among samples taken from a system. After the last sample at 12 PM was collected, the system was resanitized with 0.5% peroxide solution, flushed, recirculated and resampled. No levels of microbiological contamination were found on daily samples after the system was put back in operation. This is the reason the agency has recommended that non-recirculating water systems be drained daily and water not be allowed to sit in the system.

XI. PURIFIED WATER SYSTEMS

Many of the comments regarding equipment for WFI systems are applicable to Purified Water Systems. One type system that has been used to control microbiological contamination utilizes ozone. Figure 10 illustrates a typical system. Although the system has purported to be relatively inexpensive, there are some problems associated with it. For optimum effectiveness, it is required that dissolved ozone residual remain in the system. This presents both employee safety problems and use problems when drugs are formulated.

Published data for Vicks Greensboro, NC facility showed that their system was recontaminated in two to three days after the ozone generator was turned off. In an inspection of another manufacturer, it was noted that a firm was experiencing a contamination problem with Pseudomonas sp. Because of potential problems with employee safety, ozone was removed from the water prior to placing it in their recirculating system. It has been reported that dissolved ozone at a level of 0.45 mg/liter will remain in a system for a maximum of five to six hours.

Another manufacturer, as part of their daily sanitization, removes all drops off of their ozonated water system and disinfects them in filter sterilized 70% isopropyl alcohol. This manufacturer has reported excellent microbiological results. However, sampling is only performed immediately after sanitization and not at the end of operations. Thus, the results are not that meaningful.

Figure 11 and Figure12 illustrate another purified water system which had some problems. Unlike most of the other systems discussed, this is a one-way and not recirculating system. A heat exchanger is used to heat the water on a weekly basis and sanitize the system. Actually, the entire system is a “dead-leg.”

Figure 11 also shows a 0.2 micron in line filter used to sanitize the purified water on a daily basis. In addition to the filter housing providing a good environment for microbiological contamination, a typical problem is water hammer that can cause “ballooning” of the filter. If a valve downstream from the filter is shut too fast, the water pressure will reverse and can cause “ballooning”. Pipe vibration is a typical visible sign of high back pressure while passage of upstream contaminants on the filter face is a real problem. This system also contains several vertical drops at use points. During sanitization, it is important to “crack” the terminal valves so that all of the elbows and bends in the piping are full of water and thus, get complete exposure to the sanitizing agent.

It should be pointed out that simply because this is a one-way system, it is not inadequate. With good Standard Operational Procedures, based on validation data, and routine hot flushings of this system, it could be acceptable. A very long system (over 200 yards) with over 50 outlets was found acceptable. This system employed a daily flushing of all outlets with 80oC water.

The last system to be discussed is a system that was found to be objectionable. Pseudomonas sp. found as a contaminant in the system (after FDA testing) was also found in a topical steroid product (after FDA testing). Product recall and issuance of a Warning Letter resulted. This system (Figure 13) is also one-way that employs a UV light to control microbiological contamination. The light is turned on only when water is needed. Thus, there are times when water is allowed to remain in the system. This system also contains a flexible hose which is very difficult to sanitize. UV lights must be properly maintained to work. The glass sleeves around the bulb(s) must be kept clean or their effectiveness will decrease. In multibulb units there must be a system to determine that each bulb is functioning. It must be remembered that at best UV light will only kill 90% of the organisms entering the unit.

XIII. PROCESS WATER

Currently, the USP, pg. 4, in the General Notices Section, allows drug substances to be manufactured from Potable Water. It comments that any dosage form must be manufactured from Purified Water, Water For Injection, or one of the forms of Sterile Water. There is some inconsistency in these two statements, since Purified Water has to be used for the granulation of tablets, yet Potable Water can be used for the final purification of the drug substance.

The FDA Guide to Inspection of Bulk Pharmaceutical Chemicals comments on the concern for the quality of the water used for the manufacture of drug substances, particularly those drug substances used in parenteral manufacture. Excessive levels of microbiological and/or endotoxin contamination have been found in drug substances, with the source of contamination being the water used in purification. At this time, Water For Injection does not have to be used in the finishing steps of synthesis/purification of drug substances for parenteral use. However, such water systems used in the final stages of processing of drug substances for parenteral use should be validated to assure minimal endotoxin/ microbiological contamination.

In the bulk drug substance industry, particularly for parenteral grade substances, it is common to see Ultrafiltration (UF) and Reverse Osmosis (RO) systems in use in water systems. While ultrafiltration may not be as efficient at reducing pyrogens, they will reduce the high molecular weight endotoxins that are a contaminant in water systems. As with RO, UF is not absolute, but it will reduce numbers. Additionally, as previously discussed with other cold systems, there is considerable maintenance required to maintain the system.

For the manufacture of drug substances that are not for parenteral use, there is still a microbiological concern, although not to the degree as for parenteral grade drug substances. In some areas of the world, Potable (chlorinated) water may not present a microbiological problem. However, there may be other issues. For example, chlorinated water will generally increase chloride levels. In some areas, process water may be obtained directly from neutral sources.

In one inspection, a manufacturer was obtaining process water from a river located in a farming region. At one point, they had a problem with high levels of pesticides which was a run-off from farms in the areas. The manufacturing process and analytical methodology was not designed to remove and identify trace pesticide contaminants. Therefore, it would seem that this process water when used in the purification of drug substances would be unacceptable.

XIV. INSPECTION STRATEGY

Manufacturers typically will have periodic printouts or tabulations of results for their purified water systems. These printouts or data summaries should be reviewed. Additionally, investigation reports, when values exceed limits, should be reviewed.

Since microbiological test results from a water system are not usually obtained until after the drug product is manufactured, results exceeding limits should be reviewed with regard to the drug product formulated from such water. Consideration with regard to the further processing or release of such a product will be dependent upon the specific contaminant, the process and the end use of the product. Such situations are usually evaluated on a case-by-case basis. It is a good practice for such situations to include an investigation report with the logic for release/rejection discussed in the firm’s report. End product microbiological testing, while providing some information should not be relied upon as the sole justification for the release of the drug product. The limitations of microbiological sampling and testing should be recognized.

Manufacturers should also have maintenance records or logs for equipment, such as the still. These logs should also be reviewed so that problems with the system and equipment can be evaluated.

In addition to reviewing test results, summary data, investigation reports and other data, the print of the system should be reviewed when conducting the actual physical inspection. As pointed out, an accurate description and print of the system is needed in order to demonstrate that the system is validated.

Checklist for Microbiological Analytical Data and Reports

Checklist for review of microbiology data generated during the different tests of microbiology i.e. Antibiotic Assays, Particulate matter test, BET test, Preservative effectiveness testing ( Antimicrobial effectiveness testing), Microbial limit test (MLT), sterility, water analysis, and preservative effectiveness testing, Sterility testing. etc.

Checklist for Microbiological Analytical Data and Reports

Followings are the checkpoints during the review of microbiology data during various tests performed…

1.0       Product Information (Review of Microbiology Data) :

  • Name of material (Brand name, Generic name)
  • Pharmacopoeial status if any.
  • Manufacturer supplier name.
  • Batch No., A.R. No., Batch size.
  • Mfg. Date, Exp. Date.

2.0       General Check (Review of Microbiology Data) :

  • The Analytical method, effective date, revision number.
  • Calibration status of Instrument/Equipment.
  • Instrument/Equipment code No.
  • Instrument/Equipment usage log entry.

  • Name and grade of reagents used in the analysis.
  • Solution code no.
  • Balance ID used in the analysis.
  • Sample weight.
  • Test preparation.
  • Dilution, sonication time,filter, centrifuge of sample as per ATP .
  • Weight slip print out and any other print out with B.No. /A.R No. and signature of the analyst.
  • Date of analysis.
  • Countersignature where ever applicable.

2.0      General Check – MLT, Sterility, Water Analysis, and P.E. Testing :

  • Media used (check against respective ATP/Pharmacopoeia).
  • Media preparation date and its validity.
  • Sterilization reference no. / lot of media.
  • The pH of media.
  • Autoclave /DHS starting and end time.
  • Autoclave /DHS temperature.
  • Incubator number, calibration status of the incubator.
  • Incubation time, incubation temperature.
  • Testing preparation vs. raw data.

Related: SOP For Microbiologist Qualification

  • Type of method used.
  • Weight of the sample.
  • Dilution of the sample.
  • pH adjustment of sample preparation, if any”.
  • Entries in the respective logbooks.
  • Daily observation and countersignature of the person who has observed.

3.0      Test – Microbial Limit Test (Review of Microbiology Data):

  • Dilution factor.
  • Result in CFU/plate or CFU /gram.
  • Mean count of the duplicate plate and reporting count per g/ml
  • Method type (filtration / pour plate).
  • Additional testing, e.g. microscopic, biochemical and /or genotypic identifications.
  • Raw data for associated environmental and personal monitoring (Investigation/manipulative controls).

4.0      Test – Sterility Testing (Review of Microbiology Data):

  • Sample quantity against batch size.
  • The volume of each container used for testing.
  • Method used (filtration/direct inoculation).
  • Observation of the tubes for growth/turbidity.
  • Positive/negative controls.
  • Manipulated negative control.
  • Preparation date of tube and expiration date

5.0      Test – Water Analysis (Review of Microbiology Data):

  • Sampling quantity for chemical analysis other than TOC.
  • TOC analysis data review.
  • Microbial analysis.
  • Testing procedure vs. raw data, calculations, and results.

Related: SOP on Laminar Air flow (LAF) – Operation, Cleaning and Qualification

  • Entries in instrument usage log book.
  • Instrument code and calibration traceability in template/worksheet.
  • Calibration of instruments.
  • Sample hold time vs. analysis.
  • Trending and conclusion.
  • Positive and negative control results.

6.0      Test – Preservative Effectiveness Testing ( Antimicrobial effectiveness testing):

  • Organisms used vs. recommended in the pharmacopeia.
  • Use of preservative inactivator and concentration.
  • Culture suspension preparation procedure and raw data.
  • Amount of inoculum added.
  • Dilution of inoculum added.
  • Quantity of product used for testing.
  • Raw data and calculations for periodic testing, at different intervals.
  • Results and Conclusion as per ATP.
  • Raw data for associated environmental and personal monitoring (Investigations/manipulative controls).

7.0      Test – BET test ( Bacterial Endotoxin Test):

  • Make, expiration date and lot no. of CSE and lysate and LRW.
  • Lysate sensitivity used.
  • Qualification of lysate.
  • Qualification of LRW.
  • Sample dilution as per MVD.
  • Certificate for compatibility of lysate with CSE.
  • Added qty. of the sample, CSE, lysate, and LRW in test tubes.
  • Reconstitution, storage, and destruction of lysate and CSE.
  • Incubation condition (temperature and time).
  • Equipment no.of heating block.
  • Calibration status of the heating block.
  • Validation of the test.
  • Result of positive and negative control Vs. test procedure

8.0      Test – Area monitoring or Environmental Monitoring :

  • Exposure time, sampling location, frequency, calculations and comparison with established limits, refer test as per MLT.
  • Result of positive and negative control vs. test procedure.
  • Equipment details and their calibration status.
  • Plate counts, calculations and result data.
  • Review in EM database ( electronic database to trend results)
  • Trend data chart and conclusion.

9.0      Test – Particulate Matter Test (Review of Microbiology Data) :

  • System suitability.
  • The sample quantity and volume of air aspirated.
  • Data interpretation for zone classification.

10.0    Test – Microbiological Analysis of Compressed Air :

  • Sampling schedules
  • Sampling locations, frequency, sample volume
  • Result of the negative control (media sterility check)
  • Incubation details (time / temperature)
  • Equipment details and their calibration status
  • Plate counts, calculations and result data
  • Trend analysis and conclusions

11.0    Test – Microbiological Testing of Antibiotic Assays :

  • Media used (check against respective ATP/Pharmacopoeia).
  • Media preparation date and its validity.
  • Sterilization reference no. / lot of media.
  • The pH of media.
  • Quality testing and release of culture media.
  • Autoclave /DHS starting and end time.
  • Autoclave /DHS temperature.
  • Incubator number, calibration status of the incubator.
  • Incubation time, incubation temperature.
  • Testing preparation vs. raw data.

  • Type of method used.
  • Weight of the sample.
  • Dilution of the sample.
  • Sample extraction procedures
  • Preparation and validity of the standard stock solution.
  • Sample and standard dilutions.
  • Raw data entries in respective logbooks/ worksheets.
  • Equipment details- ID and calibration status.
  • Daily observation and countersignature of a person who has observed.
  • Plate reading, calculations, and conclusions.