Objective:
To lay down the procedure for Handling of Microbiological Data Deviation in Microbiology Laboratory.
Scope:
This procedure is applicable to environmental monitoring excursions (namely Passive air sampling, Active air sampling, Surface sampling, Personnel monitoring, and Compressed gas monitoring)obtained during the Environmental monitoring, Sterility testing, Bacterial Endotoxin Test, Bioburden, Microbial Limit test, Liquid borne particulate matter test, AET, CC-integrity tests and Water Samples.
Responsibility:
Microbiologist is responsible for implementation of the procedure and to report and carry out primary investigation.
Head Microbiology/Designee – Carryout investigation in microbiology section and ensure overall compliance of the SOP.
QA Executive/Designee -To assign the Microbiological data deviation (MDD) Number as per standard operating procedures.
IPQA Executive/Designee – To carryout the investigation in manufacturing area.
Head production/designee -To support the investigation in manufacturing area.
Head Engineering /designee -To carryout the investigation in engineering related area.
Head Quality assurance -To review the investigation in microbiology and manufacturing area.
Accountability:
Head- Quality Control is accountable for overall compliance of the SOP.
Procedure:
Definition:
Laboratory error: An error that occurs in a Laboratory associated with the performance of a test procedure, calculation error and dilution error or due to laboratory equipment malfunction or failure.
Assignable cause: A scientifically justified explanation of the reason for an out-of specification or questionable test value uncovered and documented during the investigation.
Alert Limit: Alert limits are intended to provide warnings of situations which merit investigation but not necessarily warrant corrective action. A series of excursions (3 alerts in a week in a particular manufacturing area either by same monitoring technique or from any of the monitoring techniques) beyond Alert Limits should constitute an excursion beyond an Action Limit.
Action Limit: A limits that, when exceeded, indicates a process may have drifted from its normal operating condition. Excursions beyond Action limits require a documented investigation and corrective actions to processes. Excursions beyond Action limits do not normally require consideration of action on products except when those excursions occur in Grade A areas
Negative controls: Negative controls that to be used to identify a “false positive’’ test Result.
Positive product control (PPC) for Endotoxin: An aliquot of test sample spiked with a known amount of endotoxin. This control serves as the inhibition control for gel clot assay.
Resample: A second or additional composite sample collected from a lot or a batch of drug substance or drug product by following standard sampling procedure.
Lambda (λ): For gel clot assay lambda is the labeled lysate sensitivity.
Whenever Microbiological data deviation results are obtained in below mentioned test, analyst involved in testing, will immediately inform the results to Head Microbiology/ Designee and Microbiological data deviation will be logged as per bellow:
Microbiological Data deviation Numbering procedure: QA Executive/Designee to assign the Microbiological Data Deviation (MDD) Number as below
MDD/YY/XX
Where MDD Stands for Microbiological Data Deviation
YY stands for year
XX stands for Serial Number
A log book for all Microbiological Data Deviation (MDD) shall be maintained.
Once the Microbiological Data Deviation results have been identified Head Microbiology/Designee should timely investigate (Laboratory investigation). There should be no preconceived assumptions as to the cause of failure.
Mention the results obtained and details of the findings like the date of testing and date of observation, etc.
Head Microbiology/Designee will discuss the method followed with the analyst; Review the analyst’s knowledge/ training and qualification for performing the test correctly. Investigate whether any abnormal incidence was documented during the period when the test was carried out e.g. certain obvious errors like spilling of the sample, error in transfer of the sample, power failure of equipment (incubator, LAF etc).
Procedure for Environmental monitoring excursions:
Action to be taken in case of Alert Limit Excursions
If the microbial counts are found to be more than or equal to the alert limit, log Microbiological Data Deviation (MDD) .
Notify Head -Production and Head -QA through Notification.
Notify the environmental monitoring excursions in one working day from the observation of the excursion.
Carry out the investigation .
Check for the working discipline and adherence to the standard operating procedures.
Impart training to the operators / technicians, if required.
Observe the plate(s) of the next day for any evidence of higher count.
Check the HVAC system for differential positive pressure, power failure, tripping of HVAC system, any deviation made by the operator working in the respective area and Entry log register for any new entrant. Record the details.
If the counts above the alert limits are observed i.e., 3 alerts in a week in a particular manufacturing area either by same monitoring technique or from any of the monitoring techniques, consider it as action limit and proceed for investigation as per the instructions given under Action Limit Excursions.
If out of alert limit results are observed in the critical operational area, then the sterility tubes/canisters shall be observed for evidence of any growth for the batch(s) manufactured on the day of the out of alert limit observation. Sterility tubes/canisters of batches manufactured on the previous days shall also be observed for any growth.
Action to be taken in case of Action Limit Excursions.
If the microbial counts are found to be more than or equal to the action limit, log Microbiological Data Deviation (MDD).
Notify Head -Production and Head -QA through Notification.
Notify the environmental monitoring excursions in one working day from the observation of the excursion.
Stop production and hold the release of batches manufactured during this period (from the date of monitoring and till the date of availability of investigation results)
Subject the area for disinfection and fumigation.
Carry out microbiological monitoring of the area for consecutive three days after completion of fumigation.
The area shall be released for processing only after availability of satisfactory environment monitoring data for 3 consecutive days after the fumigation.
All the batches manufactured during the period shall be subjected to the additional sampling and microbial analysis.
Check for the working discipline and adherence to the standard operating procedures.
Impart training to the operators / technicians, if required.
Check the trends and observe the next day’s results. Review the testing conditions.
Review of physical Environment condition of the room
Temperature
Relative humidity
Differential Pressure.
Non-Viable particle counts.
The observed microorganisms to be subjected for identification and shall be reviewed for the following:
Type of isolate-bacteria, yeast, molds (genus, species if required),
Is it a common environmental isolate?
Probable source of isolate (air, operators, extraneous),
Was this isolate observed before?
Is it a laboratory contamination?
Type of isolate observed whether the isolate is spore former or non sporulating organism.
Whether the contaminant is observed in critical site (Area where the product, product contact surface or containers & closures are exposed) or non-critical site.
Whether the contaminant is incidental (Excursion at only one location at a given time of exposure).
Whether the contaminant is observed as airborne or residual population over the surface of equipment/ floor/ wall.
Whether the excursion is gradually increased from exceeding alert level to action level.
Whether the excursion is repeatedly observed above alert limit in a particular location or facility.
The investigation team shall recommend corrective and preventive actions.
Any extra sampling if required, to evaluate the course of action, shall be discussed among the team and can be implemented.
Manufacturing and investigation team to ensure appropriate corrective actions recommended by QA.
Depending upon the identified probable cause take suitable corrective measures to eliminate the cause.
If reasons found for the exceeding count are related to activities in the area, cleaning, disinfection, spraying of disinfectant or fogging and fumigation shall be carried out.
Review HVAC System – air velocity, air changes and filter integrity record of LAF and HEPA filters.
Review of trend of the environmental monitoring data.
Perform additional cleaning, disinfections and fogging if high counts are observed next day.
Observe the sterility tubes for the evidence of any growth.
The investigation reports shall be submitted to the Head QA/Designee.
Quality Assurance Head shall review the investigation report and, if required, he can call for the re-qualification of the area.
These batches shall be released for dispatch only after the investigation is complete and it is confirmed that the batches manufacturing during this period are not affected.
All the investigations carried out shall be recorded in the format. The copy of this investigation report shall be maintained with respective batch manufacturing records.
If the routine personnel monitoring results are found exceeding the alert/action limits, the concerned person shall be re-trained, re-sampled at the earliest as part of the corrective action.
If a trend of over alert/action limits (routine personnel monitoring) occurs, the person shall be completely re-certified or re-assigned to new duties outside the aseptic area as part of the corrective action.
If any laboratory error is found in laboratory investigation manager microbiology shall take appropriate corrective action & evaluate the impact on the out of limit results (OOL) obtained, ensures the CAPA & send the report to QA.
If there is no laboratory error observed, for further investigation to be done in manufacturing by QA and Head production.
Note: If the excursions occur in the product contact surfaces during batch manufacturing, consider the batch rejection.
As part of the investigation, if exhaustive monitoring is planned in the areas, perform the monitoring as per an approved protocol. The protocol as a minimum shall contain the details like type of monitoring, the areas to be monitored, acceptance criteria, and the reporting formats
Endotoxin Failure investigation:
The investigation will be carried out in two Phases as:
PH I Investigation: To detect that whether the Microbiological Data Deviation (MDD) occurred in a Laboratory.
Associated with the Calculation/dilution error or due to laboratory equipment Malfunction or failure .
PH II Investigation: If no assignable cause is observed during PH I the investigation shall be extended to Manufacturing
PH I Investigation:
Carry out the PH I investigation as follows but not limited to :
Check whether the negative control test was satisfactory in both the tubes.
Check whether both tubes of PPC were positive.
Check the details of supplier of LAL reagents and the lot numbers. Also check the validity of reconstituted Lysate and CSE solutions.
Check whether reagents were qualified when the stocks was received and also check whether control curve was satisfactory and whether the LAL sensitivity was within ± 2 λ.
Review whether the test method was validated and whether the analyst was qualified for the test.
Check the calibration/Qualification status of LAL incubator, Micropipettes, sterilizer used for depyrogenation of the glassware.
Check whether depyrogenation parameters were satisfactory.
Check whether any other sample was tested along with the Microbiological Data Deviation (MDD) sample and its results.
After completion of laboratory investigation, summarize the investigation findings and conclude whether any adverse observations /laboratory errors were observed. During review, if assignable cause is identified as an obvious sampling error, or improper handling/ storage of sample, re sampling shall be done using standard sampling procedure after correcting the error.
Re sampling shall be authorized by QA (Lab Error observed/ Lab Error not observed.) The section head shall arrange for retesting on fresh three samples and analysis should be performed by another qualified analyst.
If the result of reanalysis or testing done on resample are individually within specification, the Microbiological Data Deviation (MDD) shall be invalidated and product declared as pass provided the result of other tests are as per specification. Record the investigation along with an explanation for the initial analysis failure (training and re-qualification through CAPA) result shall be retained.
If any of the triplicate tests indicate Microbiological Data Deviation (MDD) inform the Head QA/Designee to take corrective actions.
In case, no assignable cause to the Microbiological Data Deviation (MDD) test result is established, the Head Microbiology/ Designee shall intimate to Head production /designee, Head QA/Designee investigation of manufacturing process.
If the Microbiological Data Deviation (MDD) is observed with the outsourced raw material and no laboratory error/ laboratory error is found, resample and retest the batch in triplicate (Three times) by other qualified analyst.
If any of the triplicate tests indicate Microbiological Data Deviation (MDD) inform the Head QA/Designee to take corrective actions.
If any of the triplicate tests indicate no Microbiological Data Deviation (MDD), training and re-qualification of analyst through CAPA.
PH II Investigation:
Phase II investigation is carried out by a Group consisting of
Head QA/Designee
Head Production/Designee
Head Microbiology/ Designee
Carry out the PH II investigation as follows but not limited to :
Review the Batch Manufacturing record and investigate for any abnormal incidences like during manufacture of the same batch.
Review the results of the endotoxin water samples tested on the day of manufacturing the suspected batch.
Review equipment cleaning and sterilization/depyrogenation record for the batch on the day of manufacturing.
Review the depyrogenation record for containers and sampling aids used for the batch.
Check which were the raw materials used in manufacturing of the batch and review the endotoxin results of raw materials.
Review the one month environmental data of the manufacturing area/raw material storage area with respect to temperature, RH.
Review the BET results of raw materials.
Conclusion of the investigation
If the assignable cause for failure is observed during PH II investigation in the manufacturing area, reject the batch and evaluate the possible impact on the other batches manufactured in the same campaign and take the appropriate corrective and preventive actions.
If no assignable cause is observed in manufacturing carry out testing in triplicate (resample) by another qualified analyst / another qualified analyst at other Nectar lifescience units.
If the retest passes, batch can be approved and take appropriate action like retraining and re-qualification by CAPA.
If the sample fails in retest by another qualified analyst reject the batch.
Information included in the Phase II investigation report is reviewed by Head of QA, Quality Control, and Production. It is responsibility of this group to establish and document the cause of Failure and also recommend corrective action plan to prevent recurrence of such Failures in future. This group is also responsible to evaluate if there is any impact on preceding or succeeding lots of this product.
Exceeded endotoxin levels in water for injection:
If the Endotoxin exceeds the limit, immediately inform the Head-QA, Engineering Head, and Production Head. Immediately stop the usage of water for injection take the documented corrective action.
A thorough review of sampling procedure, testing procedure involving Head QA/ Designee, Head Microbiology/Designee, Head Production/Designee with analyst and perform Laboratory investigation as mentioned in Phase I.
Resample the sampling points (Which exceed the limit) and return loop sample.
Perform the analysis of the resample’s as mentioned in Phase I.
If any of the triplicate tests indicate Microbiological Data Deviation (MDD) and inform the Head QA/Designee to take corrective actions.
In case, no assignable cause to the Microbiological Data Deviation (MDD) test result is established, the Head Microbiology/ Designee shall intimate to Plant manager /designee, Head QA/Designee, Engineering Head investigation of water for injection system.
Immediate action plan for exceeded endotoxin levels in water for injection:
The action plan in case of exceeding the endotoxin limit in Water for Injection samples is given below:
Further use of WFI for Manufacturing Operations shall be suspended.
The Water System components will be corrected as applicable based on the investigation findings.
Follow an excessive sampling plan at all applicable user points for the next 03 days and correlate the test results.
Assess the impact in the applicable batch(s) in question before release of the said batch(s).
On compliance of quality of water as found in the next 03 days monitoring shall give clearance for use for further manufacturing operations.
Manufacturing Operations shall be proceeded as per Conclusion of CAPA.
Implement the changes proposed as per the conclusion of CAPA through change control system.
Time Frame :
All Microbiological Data Deviation (MDD) investigations shall be completed within 30 days of finding. Microbiological Data Deviation (MDD) result may extend with proper justification.
Failure Investigation (MLT / Bioburden)
Check, which media showed growth and at what stage of incubation. Review details of media used like sterilized media lot no., vendor lot no., validity of media, its preparation and sterilization parameters and whether the media used was satisfactory with respect to its Physical characters, growth promotion properties and its sterility as observed in negative controls.
Check the sterilization records of the media used for any deviations/abnormal incidences if any. Check the validity of load pattern followed for sterilization.
Check validity of reagents used if any.
Check if all the entries pertaining to the test have been recorded.
Check the calculations to see if any error has been observed.
Review the qualification status of the testing area/HVAC, LAF, Incubator and review the environmental monitoring data during testing of the suspect batch.
Check calibration of instruments used if any. (Micropipettes, balance, etc.)
Check qualification / validation of sterilizer.
Check whether the similar tests were carried out on any other samples along with the Microbiological Data Deviation (MDD) sample and their results.
Check whether the test method followed was validated and positive /GPT /negative controls were satisfactory.
Identify the micro-organism found in the product up to species level.
After completion of laboratory investigation, summarize the investigation findings and conclude whether any adverse observations /laboratory errors were observed.
In case if during lab investigation no assignable cause is observed Head Microbiology/Designee will discuss with the analyst during the sampling procedure followed and investigates for possibilities of sampling error.
Re sampling shall be authorized by QA (Lab Error observed/ Lab error not observed.) The section head shall arrange for retesting on fresh three samples and analysis should be performed by other qualified analyst.
If the results of the triplicate repeat test indicate no Microbiological Data Deviation (MDD), batch can be approved and analyst error is confirmed.
CAPA will be ensured by the Head Microbiology/Designee and retraining of the analyst will be conducted. Same shall be documented.
If any of the triplicate samples indicate Microbiological Data Deviation (MDD), inform the Head QA/Designee to take corrective actions and the investigation is extended to mfg in case of products mfg in-house.
If any of the triplicate tests indicate Microbiological Data Deviation (MDD) in outsourced raw material, inform the Head QA/Designee to take corrective actions.
In case if the cause of failure is assignable to the laboratory error, the initial testing is invalidated and ensure CAPA like retraining and re-qualification of the analyst. After ensuring CAPA allow the other qualified analyst to carry out the test in triplicates to assure reproducibility. If possible collect the samples from initial, middle and end of the batch.
If the retest passes batch can be approved and take appropriate action can be taken like retraining and re-qualification by CAPA.
PH II Investigation Bioburden:
Phase II investigation is carried out by a Group consisting of
Head QA/Designee
Head Production/Designee
Head Microbiology/ Designee
For further detailed investigation into Microbiological Data Deviation (MDD) result, Phase II investigation shall be initiated to determine the cause of failures.
If an Microbiological Data Deviation (MDD) result is established in Phase I investigation, a review of manufacturing process is required.
Information included in the Phase II investigation report is reviewed by Head of QA, Quality Control, and Production. It is responsibility of this Group to establish and document the cause of Failure (Final decision) and also recommend corrective action plan to prevent recurrence of such Failures in future. This group is also responsible to evaluate if there is any impact on preceding or succeeding lots of this product.
Perform the investigation of Phase I and II.
Time Frame :
All Microbiological Data Deviation (MDD) investigations shall be completed within 30 days of finding an Microbiological Data Deviation (MDD) result which may extend with proper justification.
Failure Investigation of Liquid borne particulate matter test.
Phase I
Head microbiology/Designee is responsible to review all documents related to the Microbiological Data Deviation (MDD) test results, in order to determine an assignable cause for the out of specification test result.
Failure Investigation of Liquid borne particulate matter test.
After completion of laboratory investigation, summarize the investigation findings and conclude whether any adverse observations /laboratory errors were observed. During review, if assignable cause is identified as an obvious sampling error, or improper handling/ storage of sample, re sampling shall be done using standard sampling procedure after correcting the error.
Re sampling shall be authorized by QA (Lab Error observed/ Lab Error not observed.) The section head shall arrange for retesting on fresh sample and analysis should be performed by other qualified analyst.
If the result of reanalysis or testing done on resample is within specification, the Microbiological Data Deviation (MDD) shall be invalidated and product declared as pass based on the result of other tests are as per specification. Record the investigation along with an explanation for the initial analysis failure (training and re-qualification through CAPA) result shall be retained.
If the test indicate Microbiological Data Deviation (MDD) and inform the Head QA/Designee to take corrective actions.
In case, no assignable cause to the Microbiological Data Deviation (MDD) test result is established, the Head Microbiology/ Designee shall refer the matter to Head production /designee, Head QA/Designee investigation of manufacturing process
Phase II Investigation
For further detailed investigation into Microbiological Data Deviation (MDD) result, Phase II investigation shall be initiated to determine the cause of failures.
If an Microbiological Data Deviation (MDD) result is established in Phase I investigation, a review of manufacturing process, water generation and distribution shall be carried out to identify the cause of failure.
Phase II investigation is carried out by a Group consisting of
Head QA/Designee
Head Production/Designee
Head Microbiology/Designee
Head Engineering / Designee
If no assignable cause is observed in manufacturing carry out testing of resampled sample by another qualified analyst..
If the retest passes batch can be approved and take appropriate action like retraining and re qualification by CAPA.
If the sample fails in retest by another analyst reject the batch.
Information included in the Phase II investigation report is reviewed by Head of QA, Quality Control, and Production. It is responsibility of this Group to establish and document the cause of Failure and also recommend corrective action plan to prevent recurrence of such Failures in future. This group is also responsible to evaluate if there is any impact on preceding or succeeding lots of this product.
Time Frame: All Microbiological Data Deviation (MDD) investigations shall be completed within 30 days of finding an Microbiological Data Deviation (MDD) result which may extend with proper justification.
Note: Retesting is based on the availability of sample. If possible collect the samples from initial, middle and end of the batch. Sample sending to other Nectar Lifesciences unit to be done with proper precautions and in Good packing condition.
Procedure For Sterility Failure Investigation
As soon as the initial sterility positive is observed report the results to the Head of Microbiology. Microbiological Data Deviation (MDD) will be locked as per mentioned in point number 5.2. In case of in-house manufactured products inform the failure to Production and QA department and ask to stop the production. No further batches should be manufactured until investigations are completed.
The batch showing initial sterility positive is subjected to detailed investigation to determine the cause of failure.
The batches of the same campaign which are already manufactured preceding and succeeding to the batch under suspect are kept “ON HOLD” until the investigation is completed.
Isolate and identify the sterility failure organism up to species level. In case the isolate is not identified by automated identified method (Mini API), send the isolate to outside lab for identification. Store the organism in refrigerator (2 – 8 0C) till the investigation completion of sterility and batch cannot be released till the completion of investigation.
Investigation starts in sterility testing laboratory and based on the observations, further investigation can be done. (Carry out laboratory investigation.
For outsourced raw material in case lab error is not observed, the material will be rejected and vendor will be informed to investigate the failure.
Investigation in sterility testing laboratory:
Follow the checklist of sterility failure investigation and record the observations. The investigation shall be performed by manager microbiology or designee and shall be reviewed by Manager QA or designee.
Review the sterilization records of autoclave, sterilization of media, sterility gowns, sampling vials and other sterile aids.
Review validation record of Autoclave, AHU, LAF and Garment cubicle and record the observations.
Review the Environmental monitoring record of Sterility testing area for the day of testing.
Review sampling details of the batch and incidence and corrective actions if any. Review media records, identify isolated organism. Send the isolate to outside lab in case it is not being identified by in house identification methods.
Review cleaning and disinfection procedure of microbiology lab. Review rinsing fluid and sterilization procedure. Review the entry qualification of microbiologist.
Check whether microbiologist is aware about entry exit procedure. Review environmental monitoring records of sterility testing area for past 6 months.
Summarize the laboratories overall sterility history for last two years (if applicable) stating the % failures against total no. of sterility tests carried out. Summarize the sterility testing history for the product for last three years. Summarize the total laboratory investigations and conclude whether the cause of sterility failure is assigned to a laboratory error.
During this investigation of sterility positive, if it is established unambiguously that “sterility positive” in a batch is due to laboratory failure the test is declared as invalid and can be repeated with same number of units as in the original test.
The sterility test may be invalidated in case. Microbial growths are observed in negative control and perform laboratory investigation regarding microbial growth observed in negative control as mentioned in laboratory investigation check list.
Correlation of microorganism found in environmental monitoring/ personnel monitoring of sterility test area on the day when testing was conducted and that microorganism isolated from the test sample.
If review of testing procedure used during the testing in question reveals a fault. Correlation of microorganism found in environmental monitoring / personnel monitoring of sterility test area on the day when testing was conducted and that microorganism isolated from the test sample is investigated by outside laboratory if not identified by in house identification system.
In case of the retest summarize the justification for retest and retest will be done only after approvals of Head QA or designee. If no evidence of microbial growth is found in repeat test the subject batch shall be considered to complying with the test for sterility. If microbial growth is found in repeat test, the batch will be rejected and destroyed.
If the laboratory investigation does not reveal any assignable cause or laboratory error, the batch under question will be rejected although the investigation will be extended to manufacturing area to know the assignable cause.
Investigation in Manufacturing Area:
The investigation in manufacturing area shall be performed by manager production or designee and shall be reviewed by Manager QA or designee.
Review the records for sterilization of machine parts and other product contact surfaces as well as gowns, gloves and sampling aids if applicable. Rubber stopper observations.
Review at least 2 months trend data of Temperature, RH, differential pressure, non viable particle counts and Viable Particle count.
Review the temperature record for depyrogenation of vials, manufacturing area for the day of suspected batch.
Review the cleaning and disinfection records of the manufacturing area for the day when the manufacturing of the suspect batch was carried out and for the previous day. Check whether the disinfectant used was a validated disinfectant and the lot of the disinfectant used was within the validity period.
Review validation of sterilization procedures (Autoclave etc) check the date of validation and relation with the date of materials used for manufacturing of the suspect batch.
Review Compressed gas / nitrogen gas analysis .Review Integrity testing data of all filters including air, water and HEPA filters (both terminal and of LAF units ), compressed gas/ nitrogen gas , vacuum line filter,date of last change of compressed / nitrogen gas line filter.
Review the recent Validation reports of HVAC of manufacturing area and critical area LAF. Check the date of validation of HVAC and LAF and confirm that the date of manufacturing of the suspect batch was within the validation period.
Review the data of Environmental monitoring of manufacturing area for a period of 6 months prior to the date of manufacturing the suspect batch. This will include the review of data of settle plate, air sampling and surface monitoring, personnel monitoring, nonviable particle count.
Based on the environmental monitoring trend check the frequency of environmental monitoring failure in the manufacturing area.
Check whether the sterility contaminant has been encountered in the environmental monitoring of the manufacturing area within a period of six months prior to the manufacturing of the suspect batch.
Check whether the isolation of the same organism has previously been associated with confirmed sterility failure results for any batch manufactured in the same manufacturing area.
Review Batch production record to determine if there was any event that may be associated with the contamination of the batch. Describe the unusual events if any.
Review any deviation or discrepancy associated with the batch and evaluation of impact on product quality.
Review if possible all microbiological data for raw material components used in the production of the batch and Review whether the organism was ever isolated from these components.
Review process simulation (media fill) history of the manufacturing line. Check what are the recent dates of media fills and relationship with the date of manufacturing of the suspect batch.
Summarize the number of media fills conducted, no. of units incubated and no. of units if any exhibited growth.
Review whether the sterility failure isolate is encountered anytime in the process simulations/media fills failure.
Review the validation of product sterilization method for filter sterilization of bulk solution.
Review what is the sterility testing history of the product as well as the manufacturing facility for the current and two previous years(if applicable) stating total no of batches manufactured and total no. of batches rejected for confirmed sterility failure.
Review what is the sterility testing history of the product with respect to manufacturing facility. (With respect to vendor in case of outsourced bulk).
In case of outsourced API and review sterility testing history with respect to vendor. Check how many batches the vendor had supplied and how many batches were rejected. If some of the lots in consignment received from the vendor are observed failing in sterility then evaluate the sterility of all the remaining lots. Also collect information from vendor about other lots they have manufactured in the same campaign which may have likely impact of sterility failure.
Review the personal monitoring data of the persons involved in the manufacturing of the suspect batch. Check whether the sterility failure isolate is observed in the monitoring of any person on the day of manufacturing the suspect batch, as well as on prior and subsequent manufacturing sessions.
For each person involved in manufacturing of the suspect batch review the past trend of personal monitoring. Review for each person how many times in past the person was associated with the confirmed sterility failure. Also review whether the same organism was ever encountered in the past during the monitoring of any of persons involved in the manufacturing.
Review the Microbiological monitoring data of WFI System.
Summarize the total investigation and conclude whether the batch is acceptable or rejected.
After investigation in manufacturing area, if sterility failure is confirmed, all the batches manufactured in the entire campaign will be reviewed for sterility & corrective actions will be taken followed by the sanitization/ sterilization of entire equipment chain and fogging of manufacturing area.
Incase of confirmed sterility failure, three media fill runs shall be taken irrespective of the source of contamination to ensure sterility assurance in the manufacturing area. Production can restart only on successful completion of media fill. A detailed investigation into Sterility Positive is carried out as per annexure.
The investigation should be completed within 30 working days which may extent with proper justification.
Procedure For Water Sample Failure Investigation
Interpretation Of Alert And Action Limits For Microbiological Testing:
If the total bacterial count / pathogens exceeds the alert limit .This alert, indicates that there is a potential drift in the normal operational condition which are not necessarily grounds for the definitive corrective action but which requires a follow-up investigation with production, engineering and QA personnel. User department has to log a Microbiological Data Deviation (MDD) . Investigate the probable cause i.e. check filters, pipelines, loops /valve for any leaks, defects, chokes etc.
If the total bacterial count/pathogens exceed the action limit .Immediately inform the Head-QA/QC, Engineering Head, Production Head, Immediately stop the usage of water take the documented corrective action.
A thorough investigation involving QA – Manager, Engineering – Manager, Production – Manager, shall be done.
Inform the engineering person / production person to carry out cleaning and sanitization of the system.
Once the clearance comes from QA, after sanitization microbiologist shall collect the sample from all the sampling points of that particular day and bring them to the Microbiology Laboratory for analysis. Perform above sampling and analysis another two days
If, the resample and / or all subsequent sample after sanitization shows a total bacterial count of less than alert limit then, use the water.
If, the resample and/or subsequent sample(s) after sanitization show a total bacterial count of more than alert limit , then investigate thoroughly for probable cause of failure and take corrective action.
Resample from all the user points subsequent to corrective action(s) perform the complete analysis. If sample collected, subsequent to corrective action(s) comply with the test then the water system shall be restarted.
Interpretation of Alert and Action Limits for TOC testing:
If, the TOC exceeds the alert limit .This alert, indicates that there is a potential drift in the normal operational condition which are not necessarily grounds for the definitive corrective action but which requires a follow-up investigation with production, engineering and QA personnel. User department log a Microbiological Data Deviation (MDD) as per Point number 5.2.Investigate the probable cause i.e. check filters, pipelines, loops /valve for any leaks, defects, chokes etc.
If, the TOC exceeds the action limit .Immediately inform the Head-QA/QC, Engineering Head, and Production Head. Immediately stop the usage of water take the documented corrective action.
A thorough review of sampling procedure, testing procedure involving QA – Manager, QC – Manager with analyst.
Once the clearance comes from QA, Resample the sampling points (Exceed the action limit) and return loop sample. Perform the analysis of the resample.
If, the resample and return loop sample after sanitization show TOC less than alert limit then, use the water.
If, the resample and return loop sample after sanitization show a TOC of more than alert limit , then investigate thoroughly for probable cause of failure and take corrective action.
Resample from all the sampling points of that particular day subsequent to corrective action(s) perform the complete analysis. If sample collected, subsequent to corrective action(s) comply with the test then the water system shall be restarted
Antimicrobial Preservative Effectiveness Testing (AET)
The antimicrobial effectiveness test is an extremely difficult test to perform reproducibly. It lasts for at least four weeks, has a multitude of manipulations, and relies on at best duplicate plating for its data estimation (where 5 replicates would give a much more accurate estimation of the survivors.
Due to the uncertainties of the method, a manufacturer should design formulations to greatly exceed the necessary criteria for passage, thus safeguarding the product from inadvertent failures.
Disposition of the AET
Invalid Test
If the investigation shows that the test is invalid, then this shall be noted on the data sheets and the test, with its associated investigation, closed out.
This information shall not be used to determine the adequacy of the preservative system but rather a new, valid test run.
Putative Failure
If there is no valid reason to invalidate the test it shall be considered a putative failure and as part of the investigation be confirmed.
This shall be best done by two independent AET on the same product, preferably by different microbiology analysts.
If either of these two confirmatory tests fails, then the test shall be considered a confirmed failure.
Root Cause Analysis
If during the course of the investigation it becomes apparent that the current AET is a symptom of a widespread problem, then every effort shall be made to determine the root cause of the problem and undertake corrective action.
Following investigations shall be included during Root Cause Analysis:
Investigation of cause(s)
Identify CAPA
Implement CAPA
Follow-checks on suitability/effectiveness of CAPA
Abbreviations:
EHS: Environmental Health and safety.
SOP: Standard Operating Procedure.
UV: Ultraviolet.
LAF: Laminar Air Flow.
TOC: Total organic carbon.
WFI: Water for Injection.
PH: Phase
