Chapter Phar 15

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.