Chapter Phar 15

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.

Phar 15.37 Phar 15.37 Beyond use dating.

Phar 15.37(1) (1) Sterility and stability considerations shall be taken into account when establishing a BUD. Either Category 1 and 2, or low, medium, and high-risk compounding preparation standards may be used, but not a combination of the two within the same pharmacy. The following dates and times for storage and initiation of administration of the compounded sterile preparations shall apply:

Phar 15.37(1)(a) (a) For compounded sterile preparations including components from conventionally manufactured products, the BUD shall not exceed the shortest expiration of any of the starting components. If the compounded sterile preparation includes non-conventionally manufactured products, the BUD may not exceed the shortest BUD of any of the starting components.

Phar 15.37(1)(b) (b) For Category 1 compounded sterile preparations, one of the following:

Phar 15.37(1)(b)1. 1. May not exceed 12 hours when the preparation is stored at controlled room temperature.

Phar 15.37(1)(b)2. 2. May not exceed 24 hours when the preparation is stored in a refrigerator.

Phar 15.37(1)(c) (c) For aseptically processed Category 2 processed sterile preparations, one of the following:

Phar 15.37(1)(c)1. 1. No sterility testing performed or sterility testing not passed, and prepared with one or more nonsterile starting components, one of the following:

Phar 15.37(1)(c)1.a. a. Within 1 day when the preparation is stored at controlled room temperature.

Phar 15.37(1)(c)1.b. b. Within 4 days when the preparation is stored in a refrigerator.

Phar 15.37(1)(c)1.c. c. Within 45 days when the preparation is stored in a freezer.

Phar 15.37(1)(c)2. 2. No sterility testing performed or sterility testing not passed, and prepared with only sterile starting components, one of the following:

Phar 15.37(1)(c)2.a. a. Within 4 days when the preparation is stored at controlled room temperature.

Phar 15.37(1)(c)2.b. b. Within 10 days when the preparation is stored in a refrigerator.

Phar 15.37(1)(c)2.c. c. Within 45 days when the preparation is stored in a freezer.

Phar 15.37(1)(c)3. 3. Sterility testing performed and passed, one of the following:

Phar 15.37(1)(c)3.a. a. Within 30 days when the preparation is stored at controlled room temperature.

Phar 15.37(1)(c)3.b. b. Within 45 days when the preparation is stored in a refrigerator.

Phar 15.37(1)(c)3.c. c. Within 60 days when the preparation is stored in a freezer.

Phar 15.37(1)(d) (d) For Category 2 compounded sterile preparations, terminally sterilized by a validated procedure, one of the following:

Phar 15.37(1)(d)1. 1. No sterility testing performed or sterility testing not passed, one of the following:

Phar 15.37(1)(d)1.a. a. Within 14 days when the preparation is stored at controlled room temperature.

Phar 15.37(1)(d)1.b. b. Within 28 days when the preparation is stored in a refrigerator.

Phar 15.37(1)(d)1.c. c. Within 45 days when the preparation is stored in a freezer.

Phar 15.37(1)(d)2. 2. Sterility testing performed and passed, one of the following:

Phar 15.37(1)(d)2.a. a. Within 45 days when the preparation is stored at controlled room temperature.

Phar 15.37(1)(d)2.b. b. Within 60 days when the preparation is stored in a refrigerator.

Phar 15.37(1)(d)2.c. c. Within 90 days when the preparation is stored in a freezer.

Phar 15.37(2) (2) The BUD established in sub. (1) may not be exceeded or extended for compounded sterile preparations without verifiable supporting valid scientific sterility and stability information that is directly applicable to the specific preparation or compound.

Phar 15.37(3) (3) For compounded sterile preparations which have been assigned a BUD based upon storage in a freezer, the integrity of the container-closure system with the specific compounded sterile preparation in it shall have been demonstrated for 45 days at frozen storage. The container-closure integrity test may be conducted only once on each formulation in the specific container closure-system in which it will be stored or dispensed.

Phar 15.37(4) (4) When a preservative is added, the compounded sterile formulation shall pass antimicrobial effectiveness testing that shall include inoculation of standardized microorganisms, incubation serial sampling, and calculation of the changes in colony forming unit concentrations in terms of log reduction. The results of antimicrobial effectiveness testing shall be obtained before any of the compounded sterile preparation is dispensed. Preservatives shall not be used as a substitute for good compounding practices.

Phar 15.37(5) (5) For low-risk level compounded sterile preparations, in the absence of passing a sterility test:

Phar 15.37(5)(a) (a) Within 48 hours when the preparation is stored at controlled room temperature.

Phar 15.37(5)(b) (b) Within 14 days when the preparation is stored in a refrigerator.

Phar 15.37(5)(c) (c) Within 45 days when the preparation is stored in a freezer.

Phar 15.37(5)(d) (d) For products prepared in an airflow workbench not located in a buffer area, administration shall begin within 12 hours or less of preparation.

Phar 15.37(6) (6) For medium-risk level compounded sterile preparations, in the absence of passing a sterility test:

Phar 15.37(6)(a) (a) Within 30 hours when the preparation is stored at controlled room temperature.

Phar 15.37(6)(b) (b) Within 9 days when the preparation is stored in a refrigerator.

Phar 15.37(6)(c) (c) Within 45 days when the preparation is stored in a freezer.

Phar 15.37(7) (7) For high-risk level compounded sterile preparations, in the absence of passing a sterility test:

Phar 15.37(7)(a) (a) Within 24 hours when the preparation is stored at controlled room temperature.

Phar 15.37(7)(b) (b) Within 3 days when the preparation is stored in a refrigerator.

Phar 15.37(7)(c) (c) Within 45 days when the preparation is stored in a freezer.

Phar 15.37 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18; CR 22-007: am. (1) (intro.), (c) (intro.), 1. (intro.), a., b., 2. (intro.), a., b., 3., r. (1) (c) 4., 5., am. (1) (d) 1. (intro.), 2., r. (1) (d) 3., 4., cr. (5) to (7) Register July 2022 No. 799, eff. 8-1-22; correction in (6) (b), (7) (b) made under s. 35.17, Stats. July 2022 No. 799.

Phar 15.38 Phar 15.38 Training and evaluation.

Phar 15.38(1) (1) General. The managing pharmacist, pharmacists, pharmacy technicians, pharmacy interns and pharmacy externs compounding sterile preparations shall successfully complete didactic or practical training. The didactic or practical training shall be done before any compounding personnel initially prepares compounded sterile preparations and annually thereafter and shall include all of the following:

Phar 15.38(1)(a) (a) Hand hygiene and garbing.

Phar 15.38(1)(b) (b) Cleaning and disinfection.

Phar 15.38(1)(c) (c) Measuring and mixing.

Phar 15.38(1)(d) (d) Aseptic manipulation.

Phar 15.38(1)(e) (e) Cleanroom behavior.

Phar 15.38(1)(f) (f) Sterilization and depyrogenation.

Phar 15.38(1)(g) (g) Use of equipment.

Phar 15.38(1)(h) (h) Documentation.

Phar 15.38(1)(i) (i) Use of primary engineering controls.

Phar 15.38(2) (2) Evaluation. Compounding personnel shall successfully complete an initial and annual evaluation which includes all of the following:

Phar 15.38(2)(a) (a) Visual observation of hand hygiene and garbing.

Phar 15.38(2)(b) (b) Visual observation of aseptic technique.

Phar 15.38(2)(c) (c) Gloved fingertip and thumb sampling.

Phar 15.38(2)(d) (d) Media-fill tests.

Phar 15.38(3) (3) Gloved fingertip. Successfully gloved and thumb sampling is measured by samplings resulting in zero colony-forming units no fewer than three times. Sampling shall be performed on sterile gloves inside of an ISO Class 5 primary engineering control. Gloved fingertip and thumb sampling in a RABS or an isolator shall be taken from the sterile gloves placed over the gauntlet gloves. When gloved fingertip sample results exceed action levels defined by the pharmacy, a review of hand hygiene and garbing procedures, glove and surface disinfection procedures and work practices shall be performed and documented.

Phar 15.38(5) (5) Records. The pharmacy shall maintain written policies and procedures for the initial and ongoing training and evaluation of persons involved in compounding sterile preparations. Documentation of all training, assessments, gloved fingertip tests and media-fill simulations shall be maintained by the pharmacy for 5 years and made available to the Board upon request.

Phar 15.38 History History: CR 16-085: cr. Register April 2018 No. 748 eff. 11-1-18.