Chapter Phar 15

Phar 15.32(7) (7) Visibly soiled gowns shall be changed immediately.

Phar 15.32(8) (8) Gloves shall be sterile and powder free and tested by the manufacturer for compatibility with alcohol disinfection.

Phar 15.32 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18.

Phar 15.33 Phar 15.33 Cleaning and Disinfecting the Compounding Area and Supplies.

Phar 15.33(1) (1) Compounding personnel are responsible determining the cleaning and disinfecting products to be used and for ensuring that the frequency of cleaning and disinfecting compounding area is done.

Phar 15.33(2) (2) Compounding personnel shall clean in accordance with the following:

Phar 15.33(2)(a) (a) Primary engineering control work surfaces, counters, floors and work surfaces in the buffer zone area, ante room and segregated compounding areas daily.

Phar 15.33(2)(b) (b) Walls, ceilings and storage shelving monthly.

Phar 15.33(2)(c) (c) When a spill occurs or the surface is visibly soiled.

Phar 15.33(2)(d) (d) Sporicidal agents shall be used at least weekly to clean compounding areas.

Phar 15.33(3) (3) Compounding personnel shall disinfect in accordance with the following:

Phar 15.33(3)(a) (a) Primary engineering control work surfaces at the beginning and end of each compounding business day and before each batch, but not longer than 4 hours following the previous disinfection when ongoing compounding activities are occurring.

Phar 15.33(3)(b) (b) When microbial contamination is known to have been or is suspected of having been introduced into the compounding area.

Phar 15.33(4) (4) All cleaning and disinfecting practices and policies for the compounding area shall be included in written standard operating procedures and shall be followed by all compounding and environmental services personnel.

Phar 15.33(5) (5) Cleaning, detergents and disinfection agents shall be selected and used with consideration of compatibilities, effectiveness, and inappropriate or toxic residues. The selection and use of disinfectants shall be guided by microbicidal activities, inactivation by organic matter, residue, and shelf life. Disinfectants shall have antifungal, antibacterial and antiviral activity. Sporicidal agents shall be used at least weekly to clean compounding areas.

Phar 15.33(6) (6) Storage sites for compounding ingredients and supplies shall remain free from dust and debris.

Phar 15.33(7) (7) Floors, walls, ceiling, and shelving in the classified and segregated compounding areas are cleaned when no aseptic operations are in progress. Cleaning shall be performed in the direction from cleanest to dirtiest areas.

Phar 15.33(8) (8) All cleaning tools and materials shall be low-lint and dedicated for use in the buffer room, ante room and segregated compounding areas. If cleaning tools and materials are reused, procedures shall be developed based on manufacturer recommendations that ensure that the effectiveness of the cleaning device is maintained and that repeated use does not add to the bioburden of the area being cleaned.

Phar 15.33(9) (9) Supplies and equipment removed from shipping cartons shall be wiped with a suitable disinfecting agent delivered from a spray bottle or other suitable delivery method. After the disinfectant is wiped on a surface to be disinfected, the disinfectant shall be allowed to dry, during which time the item shall not be used for compounding purposes.

Phar 15.33(10) (10) Entry points on bags and vials shall be wiped with small sterile 70% isopropyl alcohol swabs or comparable method for disinfecting, allowing the isopropyl alcohol to dry before piercing stoppers with sterile needles and breaking necks of ampules. The surface of the sterile 70% isopropyl alcohol swabs used for disinfecting entry points of sterile package and devices may not contact any other object before contacting the surface of the entry point. Particle generating material may not be used to disinfect the sterile entry points of packages and devices.

Phar 15.33(11) (11) When sterile supplies are received in sealed pouches designed to keep them sterile until opening, the sterile supplies may be removed from the covering pouches as the supplies are introduced into the ISO Class 5 primary engineering control without the need to disinfect the individual sterile supply items.

Phar 15.33 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18; CR 22-007: am. (10) Register July 2022 No. 799, eff. 8-1-22.

Phar 15.34 Phar 15.34 Immediate-use compounded sterile preparations. Immediate-use compounded sterile preparations are exempt from the requirements described for low-risk level, Category 1, and Category 2 compounding sterile preparations only when all the following criteria are met:

Phar 15.34(1) (1) The compounding process involves simple transfer of not more than three commercially manufactured sterile nonhazardous products or diagnostic radiopharmaceutical products from the manufacturers’ original containers and not more than two entries into any one container or product of sterile infusion solution or administration container or device.

Phar 15.34(2) (2) Unless required for the preparation, the compounding procedure is a continuous process not to exceed 1 hour.

Phar 15.34(3) (3) During preparation, aseptic technique is followed and, if not immediately administered, the finished compound sterile preparation is under continuous supervision to minimize the potential for contact with nonsterile surfaces, introduction of particulate matter or biological fluids, mix-ups with other compound sterile preparations, and direct contact of outside surfaces.

Phar 15.34(4) (4) Administration begins not later than 4 hours following the start of the preparation.

Phar 15.34(5) (5) Unless immediately and completely administered by the person who prepared it or immediate and complete administration is witnessed by the preparer, the compounded sterile preparation shall bear a label listing patient identification information, the names and amounts of all ingredients, the name or initials of the person who prepared it, and the exact 4-hour BUD and time.

Phar 15.34(6) (6) If administration of the compounded sterile preparation has not begun within 4 hours following the start of preparation, it shall be promptly, properly, and safely discarded.

Phar 15.34 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18; CR 22-007: r. and recr. Register July 2022 No. 799, eff. 8-1-22.

Phar 15.35 Phar 15.35 Sterilization methods.

Phar 15.35(1) (1) Sterilization methods employed shall sterilize while maintaining its physical and chemical stability and the packaging integrity of the compounding sterile preparations. The efficacy of sterilization and depyrogenation of container closure systems performed in the pharmacy shall be established, documented, and reproducible.

Phar 15.35(2) (2) Pre-sterilization requirements shall meet all of the following:

Phar 15.35(2)(a) (a) During all compounding activities that precede terminal sterilization, including weighing and mixing, compounding personnel shall be garbed and gloved in the same manner as when performing compounding in an ISO Class 5 environment. All pre-sterilization procedures shall be completed in an ISO Class 8 or better environment.

Phar 15.35(2)(b) (b) Immediately before use, all nonsterile measuring, mixing, and purifying devices used in the compounding process shall be thoroughly rinsed with sterile, pyrogen-free water and then thoroughly drained or dried.

Phar 15.35(3) (3) Sterilization shall be performed utilizing one of the following methods:

Phar 15.35(3)(a) (a) Sterilization by filtration. Sterilization by filtration involves the passage of a fluid or solution through a sterilizing grade membrane to produce a sterile effluent. Filtration may not be used when compounding a suspension when the suspended particles are removed by the filter being used. This method shall meet all of the following:

Phar 15.35(3)(a)1. 1. Sterile filters used to sterile filter preparations shall meet all of the following requirements:

Phar 15.35(3)(a)1.a. a. Be pyrogen-free and have a nominal pore size of 0.22 microns.

Phar 15.35(3)(a)1.b. b. Be certified by the manufacturer to retain at least 107 microorganisms of a strain of Brevundimonas diminuta per square centimeter of upstream filter surface area under conditions similar to those in which the compounded sterile preparations will be filtered.

Phar 15.35(3)(a)1.c. c. Be chemically and physically stable at the compounding pressure and temperature conditions.

Phar 15.35(3)(a)1.d. d. Have sufficient capacity to filter the required volumes.

Phar 15.35(3)(a)1.e. e. Yield a sterile filtrate while maintaining pre-filtration pharmaceutical quality, including strength of ingredients of the specific compounded sterile preparations.

Phar 15.35(3)(a)2. 2. The filter dimensions and liquid material to be sterile filtered shall permit the sterilization process to be completed rapidly without the replacement of the filter during the filtering process.

Phar 15.35(3)(a)3. 3. When compounded sterile preparations are known to contain excessive particulate matter, one of the following shall occur:

Phar 15.35(3)(a)3.a. a. A pre-filtration step using a filter of larger nominal pore size.

Phar 15.35(3)(a)3.b. b. A separate filter of larger nominal pore size placed upstream of the sterilizing filter to remove gross particulate contaminants before the compounding sterile compound is passed through the sterilizing grade filter.

Phar 15.35(3)(a)4. 4. Sterilization by filtration shall be performed entirely within an ISO Class 5 or better air quality environment.

Phar 15.35(3)(a)5. 5. Filter units used to sterilize compounded sterile preparations shall be subjected to the manufacturers’ recommended post-use integrity test.

Phar 15.35(3)(b) (b) Sterilization by steam heat. The process of thermal sterilization using saturated steam under pressure shall be the method for terminal sterilization of aqueous preparations in their final, sealed container closure system. The effectiveness of steam sterilization shall be established and verified with each sterilization run or load by using biological indicators, physicochemical indicators and integrators. This method shall meet all of the following:

Phar 15.35(3)(b)1. 1. All materials shall be directly exposed to steam under adequate pressure for the length of time necessary, as determined by use of appropriate biological indicators, to render the items sterile. The duration of the exposure period shall include sufficient time for the compounded sterile preparation to reach the sterilizing temperature.

Phar 15.35(3)(b)2. 2. The compounded sterile preparation and other items shall remain at the sterilizing temperature for the duration of the sterilization period. The sterilization cycle shall be designed to achieve a sterility assurance level of 10-6.

Phar 15.35(3)(b)3. 3. Compounded sterile preparations shall be placed in trays which allow steam to reach the compounded sterile preparations without entrapment of air. Paper, glass, and metal devices or items shall be wrapped in low lint protective fabric, paper, or sealed in envelopes that will permit steam penetration and prevent post sterilization microbial contamination.

Phar 15.35(3)(b)4. 4. Immediately before filling ampules and vials, solutions shall be passed through a filter having a nominal pore size of not larger than 1.2 microns for removal of particulate matter.

Phar 15.35(3)(b)5. 5. Sealed containers shall be able to generate steam internally. Stoppered and crimped empty vials shall contain a small amount of moisture to generate steam. Deep containers, including beakers and graduated cylinders, shall be placed on their sides to prevent air entrapment or have a small amount of water placed in them.

Phar 15.35(3)(b)6. 6. Porous materials and items with occluded pathways shall only be sterilized by steam if the autoclave chamber has cycles for dry goods.

Phar 15.35(3)(b)7. 7. The steam supplied shall be free of contaminants and generated using clean water.

Phar 15.35(3)(b)8. 8. The seals on the doors of autoclave chambers shall be examined visually every day they are used for cracks or damage and the seal surfaces shall be kept clean.

Phar 15.35(3)(b)9. 9. A data recorder or chart shall be used to monitor each cycle and the data shall be reviewed to identify cycle irregularities in temperature or exposure time.

Phar 15.35(3)(b)10. 10. Materials in direct contact with the compounded sterile preparation shall undergo a depyrogenation process before being sterilized using steam heat unless the materials used are certified to be pyrogen-free.

Phar 15.35(3)(c) (c) Sterilization by dry heat. Dry heat sterilization shall be used only for those materials that cannot be sterilized by steam or filtration. The effectiveness of dry heat sterilization shall be verified using appropriate biological indicators and temperature sensing devices. This method shall meet all of the following:

Phar 15.35(3)(c)1. 1. The duration of the exposure period shall include sufficient time for the compounding sterile preparation or items to reach the sterilizing temperature. The compounded sterile preparation and items shall remain at the sterilizing temperature for the duration of the sterilization period.

Phar 15.35(3)(c)2. 2. Heated air shall be evenly distributed throughout the chamber.

Phar 15.35(3)(c)3. 3. Sufficient space shall be left between materials to allow for good circulation of the hot air.

Phar 15.35(3)(c)4. 4. The oven shall be equipped with temperature controls and a timer.

Phar 15.35(3)(c)5. 5. A data recorder or chart shall be used to monitor each cycle and the data shall be reviewed to identify cycle irregularities in temperature or exposure time.

Phar 15.35(3)(c)6. 6. Materials shall first undergo a depyrogenation process before being sterilized using dry heat, unless the materials used are certified to be pyrogen-free.

Phar 15.35(4) (4) Dry heat depyrogenation shall be used to render glassware and other thermostable containers pyrogen free. The duration of the exposure period shall include sufficient time for the items to reach the depyrogenation temperature. The items shall remain at the depyrogenation temperature for the duration of the depyrogenation period. The effectiveness of the dry heat depyrogenation cycle shall be established and verified annually using endotoxin challenge vials to demonstrate that the cycle is capable of achieving at least a 3-log reduction in endotoxins.

Phar 15.35 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18.

Phar 15.36 Phar 15.36 Inspection, sterility testing and antimicrobial effectiveness.

Phar 15.36(1) (1) Physical inspection.

Phar 15.36(1)(a) (a) At the completion of compounding, the compounded sterile preparation shall be inspected by performing all of the following:

Phar 15.36(1)(a)1. 1. Visually inspect the container closure for leakage, cracks in the container, or improper seals.

Phar 15.36(1)(a)2. 2. Visually check the compounded sterile preparation for phase separation.

Phar 15.36(1)(a)3. 3. Each individual injectable unit shall be inspected against a lighted white background and a black background for evidence of visible particulates or other foreign matter or discoloration.

Phar 15.36(1)(b) (b) For compounded sterile preparations which will not be dispensed promptly after preparation, an inspection shall be conducted immediately before it is dispensed for any defects, including precipitation, cloudiness, or leakage, which may develop during storage.

Phar 15.36(1)(c) (c) Compounded sterile preparations with any observed defects shall be immediately discarded or marked and segregated from acceptable units in a manner that prevents them from being dispensed.

Phar 15.36(2) (2) Sterility Testing.

Phar 15.36(2)(a) (a) The membrane filtration method shall be used for sterility testing unless it is not possible due to the compounded sterile preparation formulation. The direct inoculation of the culture method shall be used when the membrane filtration method is not possible.

Phar 15.36(2)(b) (b) If a preparation may be needed before the results of sterility testing have been received, the pharmacy shall daily observe the incubating test specimens and immediately recall the dispensed preparations when there is any evidence of microbial growth in the test specimens. The patient and the prescriber to whom a potentially contaminated compounded sterile preparation was administered shall be notified immediately of the potential risk.

Phar 15.36(2)(c) (c) Positive sterility test results shall prompt a rapid and systematic investigation into the causes of the sterility failure, including identification of the contaminating organism and any aspects of the facility, process or personnel that may have contributed to the sterility failure. The investigation and resulting corrective actions shall be documented.

Phar 15.36(2)(d) (d) All Category 2 compounded sterile preparations made from one or more nonsterile ingredients, except those for inhalation and ophthalmic administration, shall be tested to ensure that they do not contain excessive bacterial endotoxins.

Phar 15.36(2)(e) (e) Notwithstanding par. (d), a compounded sterile preparation does not need to be tested for bacterial endotoxins if the material is stored under cool and dry conditions and one of the following:

Phar 15.36(2)(e)1. 1. The certificate of analysis for the nonsterile ingredient lists the endotoxins burden, and that burden is found acceptable.

Phar 15.36(2)(e)2. 2. The pharmacy has predetermined the endotoxins burden of the nonsterile ingredient and that burden is found acceptable.

Phar 15.36(3) (3) Antimicrobial effectiveness. Compounded sterile preparations containing a preservative added by the compounder shall pass an antimicrobial effectiveness testing with the results obtained on the specific formulation before any of the compounded sterile preparation is dispensed. The test may be conducted only once on each formulation in the particular container-closure system in which it will be stored or dispensed. The antimicrobial effectiveness test shall occur at one of the following times:

Phar 15.36(3)(a) (a) At the completion of the sterility test.

Phar 15.36(3)(b) (b) At the time of preparation for compounded sterile preparations which have not undergone a sterility testing.

Phar 15.36 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18.