Stinkhorn, Back to School and Environmental Monitoring

The summer is over, the kids are back to school, and in the Northeast it is getting cooler, darker and damper.  Already there are dead leaves on the ground and friends with allergies are popping diphenhydramine and blaming leaf mold, as good an indicator that air flora is changing as an open Malt Extract Agar settling plate.  Reflecting on these seasonal changes, on my way into the lab last week, I noticed a large fungus growing in the mulch that wasn’t there just the day before.

Mutinus elegans comes up often this time of year, poking up out of compost and dead leaves.  This phallic fungus goes by a few common names – elegant stinkhorn, dog stink horn, devil’s lipstick – because of its shape but also because it smells downright awful — like dead carrion.   As any other microbiologist would, I got down to take a good look and to snap some pictures, and noticed the sticky tips were covered with ants and flies.  The awful smell attracts these insects, which in turn help distribute the fungal spores.    This is not the sort of rude guest you want poking around your Labor Day barbecue!   Back in the straight laced Victorian day, Charles Darwin’s eldest daughter used to roam the woods around her house with a spear, collecting and burning these basidiomycetes, in order to protect “the morals of maids”.

But what interested me that morning was how quickly this thing erected itself – from spore to full on fruiting body — all in one evening.  It got me thinking about environmental monitoring.  Recent revisions to USP <797> upheld the twice a year air sampling strategy that some sterile compounding pharmacies cling to.  For me, this stink horn was a rude reminder of why this is not a sound strategy.

Microflora change in quantity and quality through the seasons.  Bacteria and mold found in spring will be much different than those found in the fall.  And even day to day, variances in humidity, wind, foot traffic, gowning, travel will impact what microbes are brought into the sterile manufacturing area – no matter how diligent the attempts to control.  We monitor the air to know what the threats are, not to triple clean and get a good grade.  We cannot react to what we aren’t monitoring.

Take a look at our laboratory data.  We monitor daily and weekly, depending on the site.  The trend witnessed in an uncontrolled ISO 8 area shows we must react more stringently at different times of year.  And we do react, with increased air filtration and sanitization.  Our reaction to the fluctuating background helps assure our clients are not wasting time with false positive test results.  (All microbial analysis is performed in ISO 5 hoods by the way, this information helps us assess what we are protecting against)   But we wouldn’t be reacting if we didn’t have these data. Imagine compounding sterile drugs with out these data.

Or conversely, consider New England Compounding Center and it’s black mold.  Interesting the owners also had a mattress recycling center about 100 feet upwind of the sterile compounding pharmacy (true polymath entrepreneurs).  Can you imagine the mold that would grow on old mattresses kept outdoors in the rain?  Whether this was the source or not, who knows.  But the fungus showed up in the fall in the lab.  Good thing they were monitoring.  Bad thing they didn’t do anything about it.  See our EM Blog for more information on how to react to Alert and Action Levels.

Perhaps the reason some sterile compounders do not monitor more frequently is cost.  But EM doesn’t have to be expensive.  For ongoing monitoring, between biannual certification events, FOCUS Labs can set customers up with equipment, media and training to perform their your own EM.  See our link on “Lab in a Box” and call us to discuss further.  What you can’t see CAN kill you, and ignorance is NOT bliss.  Let us help, give us a call.

info@FOCUS-lab.com

(610) 866-7272

USP 797 Proposed Revision July 2018 — Summary of Microbiological Testing Impact

The USP published its second proposed revision to <797> Pharmaceutical Compounding — Sterile Preparations. Significant input from stakeholders was received after the original revision a few years ago, including over 8,000 written documents.  The result is a document that looks much different than the original proposal.  Here is a high level view of changes with a microbiological impact from the original method last revised in 2008.

Categories:

There are now two categories of Compounded Sterile Product (CSP)  versus the original three of Low, Medium and High Risk.  The two categories (Category 1 and Category 2) are based on the compounding conditions, the probability of microbial growth, and the time period in which they can be used.  Basically, if you are assigning a Beyond Use Date (BUD) of >12 hours at Controlled Room Temperature (CRT) or >24 hours at refrigerated temperature, you are Category 2.  Additional testing and validation are required.

Environmental Monitoring (EM):

Disappointingly in my view, the minimum requirement for air sampling, viable and non viable, regardless of category, is still every six months.  Two single snap shots over a year’s time will not give an accurate picture of the microflora in your facility or nor are two points a trend that will expose how well your gowning, disinfecting, engineering, and other processes are under control.  See our piece about EM Investigations .  Most of our compounding customers sample more frequently than twice a year.

Surface samples have increased to at least monthly.  Unfortunately the Action Levels for Surface Samples in ISO 5 areas remain >3 cfu per contact plate.  3 colonies on a 25 cm square sterile surface where sterile compounding occurs is 3 more than what should be considered sterile.

Air levels have rightfully decreased, to <1 cfu/cubic meter in an ISO 5 PEC.

Microbial Identification:

The confusing language from the current chapter has been clarified to state that plates which exceed action level should be identified to genus with the assistance of a microbiologist. FOCUS microbiologists perform microbial identifications by either genetic or biochemical profiling, always resulting in at least a genus ID.

Media:

Recommends a single media and the following incubation times for air and surface sampling:  Tryptic Soy Agar (TSA) at 30 – 35C for 48 to 72 hours, then transferred to 20 – 25C for 5 – 7 days.  This is a change from the previous suggestion of of Malt Extract Agar.  There are advantages and disadvantages to this approach.   An advantage is saving on the cost of a specialized fungal media.  A disadvantage is the enhanced ability of MEA to actually culture wild mold versus TSA (we have data demonstrating this), and a lengthened incubation period before you can react to Action Levels.

Disinfection:

There is a much enhanced section on how to select and use antimicrobial agents for the pharmacy.  And for the first time, there is direct mention of sporicidal agents that have been shown to effective against Bacillus species, to be used at least monthly.  See our piece about disinfectant efficacy

Sterilization:

New detail is present on demonstrating that terminally sterilized CSP’s use a process to achieve a Sterility Assurance Level (SAL) of 10-6.  Validation of cycles is required, utilizing Biological Indicators including Geobacillus stearothermoophilus for steam sterilization  and Bacillus atrophaeus for dry heat sterilization.

depyrogenation:

Many pharmacies utilize depyrogenation ovens to remove potential endotoxin contamination from vials and other compounding equipment.  The proposed chapter requires that the effectiveness be established and verified annually with endotoxin challenge vials, that result in a 3 log reduction of endotoxin.

Release Testing:

All Category 2 CSP’s which have been assigned a BUD must have a sterility test performed — according to USP <71> or a validated alternative method.  There has been a lot of confusion regarding Rapid Microbial Methods (RMM) for compounded product release, with some regulators stating that anything other than USP <71> is unacceptable under any conditions.  It is encouraging to see science win out in this proposed revision.

Bacterial Endotoxin Tests are also required for all Category 2 CSPs assigned a BUD.

Preservative Efficacy Testing

If a compounded multi dose container is designed to contain more than one dose, and will be entered mulitple times, it should contain a preservative.  The proposed revisions require multi-dose preparations be tested by USP <51> Antimicrobial Effectiveness Tests.    

Conclusion:

We hope this high level review of proposed changes that may impact your microbiological testing needs has been helpful.  It is wonderful that the USP has listened to its stake holders.  We have one more chance to get our comments in.  Click here for more detail.   November 30, 2018 public comment period will close.

Meanwhile, please contact us if we can help in anyway.  All of us are FOCUSed on the same goal — patient safety.

(610) 866-7272

info@focus-lab.com

 

 

 

 

Environmental Monitoring Investigations

FOCUS Labs is sometimes the bearer of bad news.  On occasion, we need to notify a customer of a failing EM surface or air result.  We do our due diligence, and conduct an internal laboratory investigation, to be sure we didn’t contaminate the plate in the lab.  And then we report the result.

But what happens on our customer’s side of the process?  Often, the sampler is not a microbiologist and does not know what the results mean or how to react.  How many 483’s have we read where the company is diligently taking air and surface samples, recording the failing result, and then filing the report away for posterity.  No investigation, no remedial action.  How many times have I heard “Well we plan to triple clean and then sample again”.  Does that really address the root cause of the contamination or just provide a quick passing grade.  Especially in USP <797> clients, where the next exam isn’t for another six months, what is a retest after a clean going to do for patient safety?  What’s happening in your facility between sample events.

FOCUS Laboratories is providing a free investigation worksheet, to help folks think like a microbiological detective, and find the root cause of failing results. Until the root cause is uncovered and appropriate preventive action is in place, aseptic process is compromised.   You can download this worksheet from the
“Useful Forms” link on our website at http://focus-lab.com/useful_forms.html.

Some salient points – what can the microbial identification tell you about the contamination source?  What has changed in the clean room recently?  Are processes and procedures strictly adhered to?  Are routine disinfection and sterilization procedures adequate?  Has the investigation uncovered problems in documentation?  What else might be below par?

We are always available for free consultation to help you troubleshoot.  Give us a call.  Patient safety is our primary concern.  Customer service is our FOCUS.

 

Disinfectant Efficacy Testing

What is it?
Your company applies disinfectants, sporicides, and sanitizers to product contact and facility surfaces, hoping to control microbial bioburden and to prevent product contamination. But is hope really a strategy? Is it working? Are the materials and processes validated?

We aren’t talking about cleaning validations. Cleaning validations confirm that the process doesn’t leave product or cleaning residue behind, and that any microbes which might have been residing on your surfaces are knocked down.

We aren’t talking about environmental monitoring either. This is an important tool that confirms random spots in your facility are microbially acceptable on an ongoing basis.

But will your antimicrobial program actually kill elevated quantities of the microbes living in your facility? Will it kill them if they are lurking on your product contact and facility surfaces? And what about your procedure? Are the steps outlined for antimicrobial preparation, application, and contact time adequate? Disinfectant efficacy testing is a stress test, marrying elements of your EM program, cleaning validation, and cleaning process into a single verification test to confirm that you will be protected from the inevitable microbial attack.

Antimicrobials manufactured for solid surfaces are regulated by the Environmental Protection Agency under the Federal Insecticide Fungicide and Rodenticide Act (EPA FIFRA). Products are registered with the EPA after significant GLP testing. Part of this testing of course confirms antimicrobial efficacy. While rigorous, this testing doesn’t necessarily reflect what you want the product to do in your facility.   Disinfectants are registered for the EPA via the AOAC Use Dilution test. Briefly, P aeruginosa and S. aureus are deposited on stainless steel cylinders and allowed to dry. The cylinders are then soaked in the use dilution of the disinfectant for ten minutes, at which time they are retrieved and placed in a neutralizing growth medium. No growth should result from any of 180 replicates for it to be registered. While a rigorous test, it is not reflective of what’s happening in your facility. Are all of your surfaces highly polished stainless steel? Is that ATCC strain of S. aureus as resistant as the Micrococcus luteus your compounding technician is shedding into the space? Is your cleaning crew properly applying this product? And for the correct contact time?  And how long is the use dilution stable for?  Can you leave it for a week in that bottle and still expect it to be effective?

And if “because it’s the right thing to do” isn’t enough reason to perform this testing, this is a commonly found deficiency noted on US FDA 483 Audit Findings and Warning Letters.  See the end of this blog for some links to enforcement actions.

How does it work?
FOCUS Laboratories has a library of coupon materials that reflect your manufacturing environment (stainless steel, tempered glass, latex gloves, epoxy floors). We utilize coupons that are about 2 x 2 inches square.
We typically enlist the “usual suspects”, the five USP test species, to cover the different groups of objectionable microbes:

  • Staphylococcus aureus: Gram positive cocci, commonly found on humans, causes toxic shock, food poisoning, skin infections.
  • Pseudomonas aeruginosa: Gram negative rod, skin and lung pathogen, commonly found in water and soil environments.
  • Bacillus subtilis Gram positive spore forming rod. The spores are resistant to disinfection.
  • Candida albicans:   A fungal yeast, causes thrush.
  • Aspergillus brasiliensis:   A filamentous fungus.

But then importantly, we will use a few microbes that we have actually isolated from your facility during your environmental monitoring program. These are robust flora that haven’t spent generations on rich tryptic soy agar like the “usual suspects” listed above.  These are wild strains.

We dilute the wild strains to reasonable levels, spread them on the coupons, dry them for a brief period of time, follow your procedure on how to clean and disinfect that surface, and then recover any survivors.

These studies can become quite large very quickly. Imagine:

  •  5 surfaces
  •  3 antimicrobials
  •  8 test species
  •  1 contact time
  • 3 replicates

When totalled up the laboratory has 360 separate tests to perform. And that does not include demonstration of neutralization (so we are sure our contact time count is accurate) and initial counts.   FOCUS has worked out a system that allows us to wrap up these projects quickly and accurately. You should be selective in how you pick a laboratory to perform this test. There are several considerations that a lab who doesn’t have the experience will not adequately address. These include:

  • Drying time – how to dry the microbe on the surface without killing it. We have a unique method that varies for each test species.
  • Antimicrobial application – it should mimic what is actually being performed in your facility. We will need to discuss use dilution, contact time, application mechanism, rinse, etc.
  • Organism recovery – what’s the best way to get the microbes back off the coupon? Swab? Rinse? Contact plate? We have found our unique rinsing method to offer the best recovery rate. We will share the results of that study in a future blog.
  • Disinfectant neutralization – will the lab show complete kill because they haven’t neutralized the disinfectant and it’s still killing the microbes in their petri plates? Do they have data demonstrating antimicrobial neutralization? Was it performed properly?

FOCUS is a cGMP facility, so naturally we have validated our own disinfectant products, surfaces, and processes – here are some of the test data for sterile 70% IPA:

Note the lack of incomplete kill of the fungus from these results. This is why we do a daily wipe down with an EPA disinfectant product, and a weekly clean with an EPA Sterilant.   And why we have data to prove efficacy.

USP <1092> Disinfectants and Antiseptics offers more detail on why this testing is necessary and additional factors to consider. And the internet gives plenty of examples of regulatory action taken against firms who haven’t demonstrated disinfectant efficacy:

Warning Letter

NuVision483

CryoLife 483

Send us an email at info@focus-lab.com or give us a call at (610) 866-7272.  We want to discuss how we can get this done for you — quickly and affordably.  We would be happy to provide you with  a quote and a free protocol.