sop for Sterility failure investigation

1 OBJECTIVE
Investigation on sterility failure is required to find out the root cause, and to take the appropriate actions for future analysis.

2 SCOPE
This procedure is applicable to find the cause and take preventive action in case of sterility failure
detected at abc company

3 RESPONSIBILITY
Microbiologist.

4 ACCOUNTABILITY
Head – Q. C

5 ABBREVIATIONS
SOP : Standard Operating Procedure
Q .A : Quality Assurance
Q. C : Quality Control
LAF : Laminar air flow
NO. : Number
CFU : Colony forming units

6 PROCEDURE
If evidence of microbial growth is found during observation of incubated tube of batch or the batch
Tested Does not meet the requirement of sterility test. The reason for positive result shall be investigated as per the Following.
1- Laboratory investigation
2- Production & process investigation

LABORATORY INVESTIGATION:
6.1 Identification of the organism :
6.1.1. Isolate and Identify the microorganism from the test.
6.1.2 Isolate and Identify the microorganism from the environment monitoring plate of the day exposed under LAF.
6.1.3 Isolate and Identify the microorganism from the personal monitoring plate of the microbiologist performed the test.
6.1.4 If the same micro-organism is identified from the environment monitoring plate of LAF or personal monitoring plates. Then the chances of contamination from the environment or person during performing the test.

6.2 Investigation of laboratory test :
6.2.1 Identify the microbiologist performed the test.
6.2.2 Check the positive and negative control tube of the day.
6.2.3 Review the sampling & testing procedure followed by the microbiologist during the testing of the batch.
6.2.4 Review the material and/or technique used in conducting the sterility test by the
microbiologist.
6.2.5 Review the sampling procedure of the test.
6.2.6 Review the History of the test failure by the particular microbiologist.

6.3. Review of Laboratory data and records:
6.3.1 Check the results of area monitoring taken while performing sterility test.
6.3.2 Check the area cleaning record of the day
6.3.3 Check the plate exposure record of LAF of the day.
6.3.4 Check the personal monitoring record of the microbiologist and personnel working in sterile
area.
6.3.5 Check the sterilization records of the Autoclave used on the day of testing.
6.3.6 Check the calibration and validation records of all equipments used in sterility testing.
6.3.7 Review the sterilization record of the media preparation and filtration assembly used in sterility test of the batch. Also review the sterilization record of dresses, filters and equipments used in sterility testing.

6.4 Repetition of test :
6.4.1 If any abnormality found during investigation of test data or records, the positive results may be by the contamination from environment, person, equipment or procedure. The test is invalid and should be repeated. If no abnormality found then the test should be repeated for sterility failure confirmation.
6.4.2 Test should be repeated by another qualified microbiologist.
6.4.3 Test should be performed with all the precautions as per the SOP
6.4.4 Test should be performed after confirmation of all calibration and validation records.
6.4.5 If no growth is observed in re-test, the batch is passed and OOS is invalid.
6.4.6 If batch is fail in sterility then OOS is confirmed and proper investigation should be conducted
on production side to find out the root cause of sterility failure before the disposition the
batch.

PRODUCTION & PROCESS INVESTIGATION:

6.5 Monitoring of production area environment :
Trend analysis of microorganism in the critical and immediately adjacent areas in the production
department is especially helpful in determining the source of contamination in a sterility failure
investigation. Check the results of microbiological monitoring taken during aseptic operations like
dispensing of raw material, manufacturing of batch and filling of bulk solution. Identify the colony
found during the plate exposure in production area on testing date. Also check the area cleaning record and disinfectant usage record in production area. If colony observed in production area is the same as found in repeat test, there are chances of contamination from environment.

6.6 Monitoring of personnel :
Check the personnel monitoring data of the microbiologist and personnel working in sterile area of
production department. Identify the colony found during the personnel monitoring. If the colony observed during personnel monitoring is the same as found in test, there are chances of contamination from the personnel.

6.7 Product bioburden testing :
Reviw the trend of bioburden testing
a) Bioburden testing from mixing tank and holding tank.
b) Bioburden testing of in-process product samples

6.8 Review of sterilization cycle :
Review the sterilization record of dresses, filters and equipments used in during batch preparation as well as sterilization record of filled bottles.

6.9 Review of production records :
6.9.1 Complete batch and production control records should be reviewed to detect any sign of
failure that could have a bearing on product sterility. The investigation should include
elements such as:
6.9.1 Events that could have impacted on critical zone.
6.9.2 Batch and trending data that indicate whether utility or water system are functioning properly.
For instance records of air quality monitoring could show time at which there was or an
unusually high particle count or high CFU found in water system
6.9.3 Whether construction and maintenance activities could have an adverse impact on sterility of
Product.

6.10 Manufacturing history :
The manufacturing history of a product should be reviewed as a part of investigation. Past
deviations, problems or changes (Process, components, equipment) are among the factors that can provide an indication of the origin of the problem.
Appropriate corrective and preventive actions shall be carried out for any of the above reason which Contributed in sterility failure

6.11 Preparation of report:
Proper report of sterility failure investigation is prepared as the Annexure-2.

6.12 Incase of Market complaint
If there is a complaint against product from market,
6.12.1 Immediately call the party to stop the further distribution of the related batch.
6.12.2 Ask to send samples for sterility test (sample sufficient for 2 analyses) from the complaint source.
6.12.3 At the same time collect one sample bottle of the related batch from Control samples &
test for sterility for verification about the geniuses of the complaint
6.12.4 Review of all the points given above under lab investigation will be done.
6.12.5 Send samples for sterility test to an outside government approved laboratory.
6.12.6 The sterility test will be performed in-house by another qualified microbiologist.
6.12.7 Decision shall be taken on the basis of results of IH sterility testing and outside laboratory
sterility test.

07 FREQUENCY
Whenever sterility test failed

08 ENCLOSURES
ANNEXURE -1 Sterility failure intimation
ANNEXURE -2 Sterility failure investigation Report
ANNEXURE- 3 Change History Log Format

ANNEXURE-2
Sterility failure investigation report

1– Batch Details

Product Name		Batch #
Date of Manufacturing		Filling Room #
Product Code (if any)		Filling Machine
Terminally sterilized		Autoclaved lot No.

2- Sterility Test Details

Date	Name of Microbiologist
Time of test performed	Number of Test performed at same time
Validated test method	Tested to Specification
Date of results	Test session results	With positive growth— With positive growth—
Positive control result	Negative control result

3 Batch review from manufacturing and testing.

Review of raw

materials used for

the manufacture

Checked – OK /Not OK

Batch #

Materials code #

Results of tests

Checked – OK /Not OK

Sign:

Date:

Review Attached: Yes/No

Dispensing of the

raw materials

Checked – OK /Not OK

Sign:

Date:

Review Attached: Yes/No

Sterilization cycles

for components /Utensils

Autoclave#

Cycle#

Date

Result

Sign:

Date:

Review Attached: Yes/No

Solution Preparation results:

Distilled water used

for manufacturing

Date /Time of collection

Date/ Time of performance

Results

Sign:

Date:

Review Attached: Yes/No

Review Bulk solution

Bio-burden

Date /Time of collection

Date/ Time of performance

Results

Sign:

Date:

Review Attached: Yes/No

Review of Filled

Container Bio-burden

Date /Time of collection

Date/ Time of performance

Results

Sign:

Date:

Review Attached: Yes/No

Review of Bacterial

Endotoxins results

Date /Time of collection

Date/ Time of performance

Results

Sign:

Date:

Review Attached: Yes/No

Line steaming results

Line #

Date

Result

Sign:

Date:

Review Attached: Yes/No

Batch manufacturing Vessel steaming results

Mixing tank #

Date

Result

Sign:

Date:

Review Attached: Yes/No

Holding tank results

Holding Tank #

Date

Result

Sign:

Date:

Review Attached: Yes/No

Filtration review

filter #

Date

Results

Sign:

Date:

Review Attached: Yes/No

Environmental monitoring results

Filling machine room

Viable count -Air

Exposure time count

Under LAF-

Filling Room-

Corridor-

Sign:

Date:

Review Attached: Yes/No

Filling machine room

Viable count -settle plate

Exposure time count

Under LAF-

Filling Room-

Corridor-

Sign:

Date:

Review Attached: Yes/No

Filling Machine room

Non-viable particulates count

Under LAF-

Filling Room

Corridor

Sign:

Date:

Review Attached: Yes/No

Manufacturing room

Viable count

Settle plate –

Air sampling=

Surface wall-

Sign:

Date:

Review

Attached: Yes/No

Manufacturing room

Non- Viable count

Count

Sign:

Date:

Review

Attached: Yes/No

Review of Prepared

plate media

Type of Media

Batch #

Expiry Date

Sign:

Date:

Review

Attached: Yes/No

Filling Machine results:

Setting up

Procedures

Sign:

Date:

Review Attached: Yes/No

Machine wash water

results

Machine #

Date

Result

Sign:

Date:

Review Attached: Yes/No

Error log report

Report

Date

Result

Sign:

Date:

Review Attached: Yes/No

Filtering review

Sterilization filter #

Date

Results

Sign:

Date:

Review Attached: Yes/No

Manufacturing

instruction sheet

review

Interventions

Stoppages

Reject rate

Sign:

Date:

Review Attached: Yes/No

Maintenance log

review

Sign:

Date:

Review Attached: Yes/No

Pressure testing

calibrations

Sign:

Date:

Review Attached: Yes/No

Differential pressure

excursion review

Sign:

Date:

Review Attached: Yes/No

Filling Process

Sign:

Date:

Review Attached: Yes/No

All shifts

Sign:

Date:

Review Attached: Yes/No

Sterilization review

Sign:

Date:

Review Attached: Yes/No

Cooling water supply review

Sign:

Date:

Review Attached: Yes/No

Product line integrity

Sign:

Date:

Review Attached: Yes/No

Log Book

Sign:

Date:

Review Attached: Yes/No

Sterile Operator Review

Name and Number

of Operators &

Location of working

Name

Location

Sign:

Date:

Review Attached: Yes/No

Interview of Operator

for any excursion of

procedures:

Name:

Date

Sign:

Date:

Review Attached: Yes/No

Training records

Gowning validations

Name

Training Record

Sign:

Date:

Review Attached: Yes/No

Operators Finger

Dabs

Name

Results

Sign:

Date:

Review Attached: Yes/No

Operators personal monitoring record

Name

Results

Sign:

Date:

Review Attached: Yes/No

QA Review Manufacturing:

Product Review of

past 12 months of

results

Sign:

Date:

Review Attached: Yes/No

Deviation Reports

Review

Sign:

Date:

Review Attached: Yes/No

Similar incidents

Sign:

Date:

Review Attached: Yes/No

Change control

history review

Sign:

Date:

Review Attached: Yes/No

Review of Media run

reports past 12

months

Sign:

Date:

Review Attached: Yes/No

Sterility Testing Review

REVIEW AREA

DETAILS

REVIEWED BY

Results of known

sterile controls

Sign:

Date:

Review Attached: Yes/No

Level of false

positives in routine

testing (previous 12months)

Sign:

Date:

Review Attached: Yes/No

Level false positives

in known sterile

controls previous 12

months)

Sign:

Date:

Review Attached: Yes/No

Review of sampling

procedures

Sign:

Date:

Review Attached: Yes/No

Review of handling

procedures

Sign:

Date:

Review Attached: Yes/No

Review of swab

method

Sign:

Date:

Review Attached: Yes/No

Review of certificate

for Sterile test unit

Sign:

Date:

Review Attached: Yes/No

Review of autoclave

cycle for sterility test

equipment

Sign:

Date:

Review Attached: Yes/No

Media used in

sterility test

Sign:

Date:

Review Attached: Yes/No

Validation of HEPAs

Sign:

Date:

Review Attached: Yes/No

Validation of

Laminar Flow unit

Sign:

Date:

Review Attached: Yes/No

Review of sterility

test session, other

batches

Sign:

Date:

Review Attached: Yes/No

Training records for

Microbiologist

Sign:

Date:

Review Attached: Yes/No

Environment monitoring results for the sterility test room

Viable –Air

Air- LAF

Air -Sterility Test room

Air -Change room

Sign:

Date:

Review Attached: Yes/No

Environment monitoring for the

sterility test room

Viable- Settle plate for the test time

Settle- LAF-

Settle- Room

Settle- Change room

Sign:

Date:

Review Attached: Yes/No

Environment monitoring results for the sterility test room

Non- Viable

Under- LAF-

Sterility test room-

Change room

Sign:

Date:

Review Attached: Yes/No

Review of Prepared

plate media

Type of Media

Batch #

Expiry Date

Sign:

Date:

Review Attached: Yes/No

Sterility -Microbiologist

Finger Dabs

Sign:

Date:

Review Attached: Yes/No

Sterility -Microbiologist

Uniform

Sign:

Date:

Review Attached: Yes/No

Differential pressure

excursion review

Sign:

Date:

Review Attached: Yes/No

Cleaning review

Sign:

Date:

Review Attached: Yes/No

Disinfectants for

cleaning

Sign:

Date:

Review Attached: Yes/No

Interview of Microbiologist

Sign:

Date:

Review Attached: Yes/No

Sterility Log Book

Sign:

Date:

Review Attached: Yes/No

4. Summary of Conclusions found

5. Possible cause/ Root Cause

6. Corrective action

Task	Responsible	Date Completed

7 Disposition of batch/Lot

8. Documentation Approval of Investigation

Prepared by (Microbiologist)	Signature	Date
Reviewed by 1( Sr. Microbiologist)	Signature	Date
Reviewed by 2 ( Q.C . manager)	Signature	Date
Approved by Quality Assurance Manager	Signature	Date