Standard operating procedure for handling of Microbiological Data Deviation.
1.0 OBJECTIVE:
1.1 To provide the requirements for handling of Microbiological Data Deviation.
2.0 SCOPE:
2.1 The procedure is applicable to all Microbiological testing methods. 2.2 The procedure is applicable for all investigation & evaluation of Microbiological Data Deviation such as Alert/Action limit excursion, Out of Specification (OOS) in Microbiological analytical results / observation in Microbiology Labs (Microbial Enumeration test, Test for specified microorganisms, Sterility test, water quality monitoring , Environmental monitoring and BET testing).
3.0 RESPONSIBILITY:
3.1 Microbiologists/Trained personnel 3.1.1 To inform the data deviation in any specific test immediately. 3.1.2 To participate in the investigational process. 3.1.3 To perform the activities as per procedure. 3.1.4 To report any non compliance to the procedure. 3.2 Head-Microbiology/Designee 3.2.1 To ensure the activities are performed as per procedure 3.2.2 To initiate the process of investigation and complete the same as per procedure. 3.2.3 To ensure the activities are performed as per the laid down schedules.
4.0 ACCOUNTABILITY :
4.1 Head Quality Control/Designee 4.1.1 To ensure the procedure is implemented at their site 4.1.2 To participate & coordinate in the process of investigation 4.1.3 To investigate any non compliance to the procedure. 4.2 Head Manufacturing/Designee 4.2.1 To ensure the procedure is implemented at their site. 4.2.2 To participate & coordinate in the process of investigation 4.2.3 To ensure the activities are performed as per procedure 4.2.4 To investigate any non compliance to the procedure. 4.3 Head Engineering/Designee 4.3.1 To ensure the procedure is implemented at their site. 4.3.2 To participate & coordinate in the process of investigation 4.3.3 To ensure the activities are performed as per procedure 4.3.4 To investigate any non compliance to the procedure. 4.4 Head Quality Assurance/Designee 4.4.1 To ensure the implementation of procedure at their site. 4.4.2 To review and approve the investigation and close the relevant record. 4.4.3 To verify investigation of any non compliance to the procedure.
5.0 PROCEDURE:
5.1 Identifying and assessing of Microbiological Data Deviation:5.1.1 Analyst is responsible to perform analysis as per standard procedure and / or pharmacopoeia, in case of any excursion from the laid down limits/levels (Alert/Action limit) and excursion from Specification limit (OOS result) is noticed by the analyst during analysis, analyst shall immediately inform to Head Microbiology/Quality Control or his Designee.5.1.2 Head - Microbiology or Head-QC or Designee shall review the data as per standard operating procedure and discuss with Analyst regarding the entire procedure followed for analysis.5.1.3 If the excursion is from the Alert /Action limit in Environment Monitoring and Water Quality Monitoring samples then an intimation of the excursion shall be given through appropriate format as mentioned in CSOP on Environment Monitoring and Water Quality Monitoring.5.1.4 Analyst shall preserve all media, plates, test tubes; culture dilutions including all glassware (which are available on the day of the observation for excursion) used for the investigation and identification purposes.5.1.5 If after discussion and verifying all criteria/data, if it is found that the analytical results are out of specification, the laboratory investigation shall be carried out.5.1.6 The test solution, media plates, test tubes, culture dilutions etc. shall be transferred to temperature controlled chamber maintained at 2-8ºC till the investigation is completed and a disposition decision is taken by Head QC/Head QA.5.1.7 If the samples, test solution, media plates, test tubes etc. are not available, recorded data shall be reviewed.5.1.8 The analyst shall get the OOS Laboratory Investigation form from QA and fill the details.5.1.9 Authorized QA person shall allocate the unique alphanumeric identification numbering of OOS as mentioned below:MBL/OOS/19/XXX/001Where:MBL : Microbiology LabOOS :Out of Specification19 : Last two digits for Year of OOS observationXXX : Name of the test001 : Serially numbered OOS No. 5.1.10 Thus first OOS observed in environment monitoring would be given an OOS No. as MBL/OOS/19/EMP5.1.11 Code of Test name given below in table:5.1.12 Authorized QA person shall provide the OOS number and enter the initial details of the OOS in the OOS Laboratory Investigation Form5.1.13 The OOS Investigation form after entering initial details shall be given to Head QC /Head Microbiology/Designee for further investigation.5.1.14 The investigation shall be thorough, timely, unbiased, well documented and scientifically defensible. Investigation shall be justified by an assignable root cause.5.1.15 There is no need for a formal laboratory investigation in situations like instrument/equipment failure, power failure, in-complete transfer of a sample which are identified immediately, spillage of sample solution, etc. Such cases shall be handled through SOP on Laboratory incident handling.5.1.16 If errors are obvious, such as the spillage of a sample solution, increase in the temperature of equipment is identified or the incomplete transfer of the sample is observed, the analyst should immediately document the same and put remarks for invalidation on the analytical raw data and take necessary action. Analysts should not knowingly continue an analysis they expect to invalidate at a later time for an assignable cause. It shall be handled through SOP of Laboratory incident handling if analyst observed event online before obtaining of results.5.1.17 If multiple OOS are observed in Environment and Water Samples for a day then one OOS No. shall be allotted for a day for one area/water system and all the various observations for various tests shall be included in one OOS.5.1.18 If consecutive sampling shows out of specification results, the monitoring shall be stopped in consultation with QA and shall be resumed only after appropriate measures are taken to reduce the microbial load in the area/water system.5.1.19 If a person shows a high count in the consecutive sampling days in personnel monitoring, then the person shall not be allowed to work in the aseptic areas and counselling and training of the personnel shall be conducted.5.1.20 Upon satisfactory personnel re qualification the person shall be allowed to enter in the aseptic manufacturing area. The details shall be documented appropriately.5.1.21 If the excursion/OOS is of a repeated nature for a location or observed on consecutive days then all the excursion and OOS shall be investigated through one Excursion no./OOS ID and no separate excursion/OOS nos. shall be generated.5.1.22 If multiple OOS are observed for a location/water system and no corrective action is effective then an increased sanitization of the area/system shall be carried out and if required the frequency of sanitization shall be revised, care shall also be taken to reduce/restrict handling of sample. If required, check for any change in the sanitizing agents based on the isolated organisms shall also be done.5.1.23 Under such circumstances Head QA in consultation with Corporate Quality shall take a decision on the manufacturing activities in the area.5.1.24 If required an appropriate risk assessment shall be prepared to evaluate the impact of the excursions/OOS on the quality of product/s. 5.2 Microbiological Data deviation during Media Growth Promotion:5.3.1 Following data deviation can be observed during media growth promotion: 5.3.2 Growth observed in negative control tubes/plates or in plates for the Test of Inhibition:5.3.2.1 The reason could be analyst error during handling/preparation/inoculation of the media.5.3.2.2 Identify the particular colonies and study the characteristics.5.3.2.3 If colony observed is one of the in house isolates, check the whole lot of media tubes or plates.5.3.2.4 If many of the media containers are showing growth without inoculation check whether the steam sterilizer is in calibrated state during sterilization of media.5.3.2.5 Check for proper functioning of steam sterilizer. If required, re-validate the instrument.5.3.2.6 Dispose off the entire lot of media and proceed for investigation as per CSOP on Procedure for Media Management CSOP/2014/015 and the formats mentioned in the CSOP shall be taken for investigation.5.3.2.7 Thoroughly evaluate the samples analyzed using that particular media.5.3.2.8 If any failure is observed and the media has been used for any sample analysis before GPT release, disregard the analysis and re analysis shall be carried out of those samples using fresh and approved lot of media. 5.3.4 Growth is not detected/accepted recovery is not obtained in Positive control/Indicative test:5.3.4.1 Check for calculation error, wrong inoculation, if any.5.3.4.2 Check whether culture inoculum dilution added is valid for used5.3.4.3 If culture is valid, whether inoculum procedure followed is correct.5.3.4.4 Check for incubation conditions are appropriate.5.3.4.5 Check for media should not be over heated during sterilization or heating or re melting.5.3.4.6 Check for whether steam sterilizer/incubator is in calibrated state during sterilization/incubation of media.5.3.4.7 Check for proper functioning of instrument/equipment, if required; re validate the instrument/equipment.5.3.4.8 Dispose off the entire lot of media and proceed for investigation.5.3.4.9 Thoroughly evaluate the samples analyzed using that particular media.5.3.4.10 If any failure is observed and the media has been used for any sample analysis before GPT release, disregard the analysis and re analysis shall be carried out of those samples using fresh and approved lot of media. 5.4 Microbiological Data deviation during Pure culture maintenance:5.4.1 Growth not observed during plating for inoculum preparation:5.4.1.1 Check for the viability/expiry of the culture.5.4.1.2 Check for the proper handling techniques used.5.4.1.3 Check for appropriate incubation/storage conditions.5.4.1.4 Investigate the reason for the incidence.5.4.1.5 Revert to stock culture passage tube for fresh inoculum preparation.5.4.1.6 Check for calibration status and proper functioning of Incubator and cold chamber. If required re validate the instrument.5.4.1.7 If growth is not observed further then procure fresh culture. 5.4.2 Contamination observed in pure culture plates/slants:5.4.2.1 Check for the proper handling techniques during inoculum preparation.5.4.2.2 Identify the particulars of the contaminant colony.5.4.2.3 Investigate the reason for the incidence.5.4.2.4 Revert to stock culture passage tubes for fresh inoculum preparation.5.4.2.5 If pure culture is still not obtained then procure fresh culture. 5.5 Microbiological Data deviation during testing of pre sterilized items and diagnostic kits used in Microbiology Lab:5.5.1 If results are unusual then the materials shall be rejected and sent back to the manufacturer immediately.5.5.2 The material shall not be used for any further testing. 5.6 Causes of OOS Test Result5.6.1 Assignable cause: An assignable cause is an identifiable, specific cause of variation in an analysis or measurement. A cause of variation that is not random and does not occur by chance is "assignable"5.6.2 If assignable cause is found then the analysis shall be considered void.5.6.3 Some of the common Laboratory error during analysis are as follows, but not limited to:,5.6.3.1 Error in sampling, handling or storage of sample5.6.3.2 Error in following the method of analysis: Incorrect method used, wrong instrument used, parameters not correctly used.5.6.3.3 Error in usage of media and culture suspensions.5.6.3.4 Error during sterilization of media and accessories used in testing.5.6.3.5 Error in cleaning and sanitization of testing facility.5.6.3.6 Error during observation.5.6.3.7 Error in calculation/ typographical mistakes.5.6.3.8 Due to instrument/equipment malfunction identified at the time of OOS5.6.3.9 Use of non calibrated instruments & / or apparatus.5.6.3.10 Use of invalid / incorrect working standard due to mishandling of working standard or use of wrong working standard5.6.3.11 Use of contaminated glass wares and apparatus.5.6.3.12 Lack of training / knowledge of analyst5.6.3.13 Use of expired or old chemicals, reagents, medias, cultures or solvents.5.6.3.14 Improper storage and handling of samples.5.6.3.15 Error in sampling, handling or storage of materials5.6.3.16 Inadequate transfer of sample / solution / Wrong weighing /due to analytical error like dilution/filtration/sonication or extraction etc.5.6.3.17 Software error due to software malfunctioning5.6.3.18 Cross contamination during analysis5.6.3.19 Others if any.5.6.4 Non – assignable cause: In such cases where no assignable root cause identified,, additional data must be generated to assess whether the initial a typical result is a statistical outlier. 5.7 Excursion in Microbial Counts (Air/Surface/Personnel/Drain Monitoring) beyond Alert Limit-5.7.1 If count is observed higher than alert limit then the Analyst shall fill the OOS format.5.7.2 Authorized QA person shall allocate the unique alphanumeric identification number for the excursion.5.7.3 Intimation shall be received by Area In charge and activity based on the requirement shall be performed and mentioned in format.5.7.4 When microbial counts exceed the alert limit increase the cleaning and sanitization in the area with double frequency till counts come to normal (if required).5.7.5 Review the results of the previous day and days before and after the observation date, to evaluate whether the observation is localized, one of case or systemic.5.7.6 If Microbial counts are beyond alert limit for 3 consecutive days then the same shall be considered as an excursion beyond action limit and the measures shall be taken up according to the action limit excursion.5.7.7 Monitoring of the area with routine frequency can provide assurance for the area status. 5.8 Excursion in Microbial Counts of Air Monitoring beyond Action Limit-5.8.1 If count is observed higher than action limit then the Analyst shall fill the OOS format.5.8.2 Authorized QA person shall allocate the unique alphanumeric identification number for the excursion.5.8.3 Investigation for any possible laboratory error shall be performed if counts are observed higher than action limit parallelly with the process level investigation (Manufacturing investigation).5.8.4 When microbial counts of area (Settle plate exposure or Air sampling) exceeds the action limit, follow the action plan as given below:5.8.4.1 Check manometer reading and particle count of area.5.8.4.2 Review the results of the previous day and days before and after the observation dates, to evaluate whether the observation is localized, one of case or systemic.5.8.4.3 Investigate the reason for the excursion in the format.5.8.4.4 If above tests are found within specified limit, increase the cleaning and sanitization in the area with double frequency or as per requirement based on the contamination observed.5.8.4.5 Increase frequency of microbial monitoring to twice in a day for three days for Sterile Manufacturing areas /Sterility Testing area.5.8.4.6 Perform microbial monitoring for three days for Non Sterile Manufacturing areas /other testing areas of Microbiology Lab.5.8.4.7 If any of the microbial monitoring results is not found within specified limit, stop the activities (Manufacturing/Filling/Testing) in the area.5.8.4.8 Engineering department shall be called for the corrective action as per applicable site specific SOPs.5.8.4.9 The investigation shall include the following but not limited to-Review level of personnel activity in the area on that day-Review/perform airflow patterns and HEPA integrity tests results during last qualification-Review aseptic technique of personnel and training records-Review gowning procedures and other requirements for area-Review trends and any incidents of HVAC outages, if they occurred-Inspect incoming air filters for leaks and pressure differential across filter-Review room disinfection and sanitization procedures, sanitization intervals and disinfectant efficacy.-Review the concentration of disinfectant used for the sanitization activity and is as per the validated disinfectant concentration.-Review training records of individuals performing sanitization or disinfection-Check area pressure differentials, particularly with respect to the last sanitization-Evaluate mechanical equipment in the area as possible source of contamination-Review relevant, recent data at the same sites and subsequent monitoring results available.-Review sterilization cycle documentation and records.5.8.4.10 After corrective action perform the microbial monitoring of the area with increased frequency of twice in a day for three consecutive days for Sterile Manufacturing areas /Sterility Testing area for that specific location.5.8.4.11 Perform microbial monitoring for three days for Non Sterile Manufacturing areas /other testing areas of Microbiology Lab for that specific location.5.8.4.12 After completion of investigation and CAPA, Investigation report shall be submitted to QA for closure within a period of NMT 20 working days. If the investigation is not completed within the timeline then a delay justification shall be given. 5.9 Excursion in Microbial Counts of Surface/Drain Monitoring beyond Action Limit-5.9.1 If count is observed higher than action limit then the Analyst shall fill the Format.5.9.2 Authorized QA person shall allocate the unique alphanumeric identification number for the excursion.5.9.3 Investigation for any possible laboratory error shall be performed if counts are observed higher than action limit parallelly with the process level investigation (Manufacturing investigation).5.9.4 In case of microbial count of surfaces exceed the action limit:5.9.4.1 Investigate the reason for the excursion in format.5.9.4.2 Review the results of the previous day and days before and after the observation date, to evaluate whether the observation is localized, one of case or systemic.5.9.4.3 Check that the disinfectant used is as specified for surface sanitization.5.9.4.4 Increase the cleaning and sanitization with double frequency or as per requirement based on the contamination observed.5.9.4.5 Train the personnel for clean room practices.5.9.4.6 Increase frequency of surface monitoring to twice in a day for three days for Sterile Manufacturing areas /Sterility Testing area for that specific location.5.9.4.7 Perform surface monitoring for three days for Non Sterile Manufacturing areas /other testing areas of Microbiology Lab for that specific location.5.9.4.8 If any of the surface monitoring results is not found within specified limit, stop the activities (Manufacturing/Filling/Testing) in the area.5.9.4.9 Engineering department shall be called for the corrective action as per specific SOPs.5.9.4.10 The investigation shall include the following but not limited to-Perform investigation for possible sources of contamination.-Evaluate sanitization and disinfection practices, review preparation of disinfectants, cleaning records, and training records of individuals performing sanitization and disinfection.-Review possible unusual events during manufacturing /testing operation-Examine areas during operation for the day of further monitoring to understand behaviour and practices of personnel-Review closed circuit video (if applicable)-Verify that controls were not circumvented-Review risk of product contact-Review isolates for occurrence in other types of tests-Evaluate integrity of the room (e.g. Peeling of paints or cracks in ceiling, walls and floor)-Examine Endotoxin and water chemical test data for the system-Review for the excursion in water samples used for cleaning and disinfection purposes.5.9.4.11 After corrective action perform the surface monitoring of the area with increased frequency of twice in a day for three consecutive days for Sterile Manufacturing areas /Sterility Testing area.5.9.4.12 Perform surface monitoring for three days for Non Sterile Manufacturing areas /other testing areas of Microbiology Lab.5.9.4.13 After completion of investigation and CAPA Investigation report shall be submitted to QA for closure within a period of NMT 20 working days If the investigation is not completed within the timeline then a delay justification shall be given in format. 5.10 Excursion in Microbial Counts of Personnel Monitoring beyond Action Limit-5.10.1 If count is observed higher than action limit then the Analyst shall fill the Format.5.10.2 Authorized QA person shall allocate the unique alphanumeric identification number for the excursion.5.10.3 Investigation for any possible laboratory error shall be performed if counts are observed higher than action limit along with the process level investigation in Manufacturing investigation.5.10.4 Investigate the reason for the excursion.5.10.5 The investigation shall include the following but not limited to-Evaluate possible operator impact on product-Review current environmental monitoring data and sterility test data-Review preparation and expiry dates for disinfectants used on gloves-Identify all morphologically unique isolates(human vs environmental)-Interview operator for potential cause and retrain or re qualify operator.-Evaluate training of operator-Review sanitization and disinfection records of area-Review closed circuit video (if applicable)-Review previous gowning data for the operator and other operators on the same day. 5.10.6 In case of microbial count of finger dabs/gown monitoring of personnel exceed the action limit:5.10.6.1 Train the personnel for clean room practices.5.10.6.2 Review the results of the previous day and days before and after the observation date for the personnel, to evaluate whether the observation is localized, one of case or is being identified routinely for the person.5.10.6.3 Increase the frequency of personnel monitoring to twice in a day for three consecutive days for Sterile Manufacturing areas /Sterility Testing area for that specific personnel. 5.10.6.4 If still the counts of specific personnel are showing excursion, the person shall not be allowed to perform any aseptic handling in the area and shall be only allowed after complete personnel qualification as employed for an initial personnel qualification of a personnel.5.10.6.5 After completion of investigation and CAPA Investigation report shall be submitted to QA for closure within a period of NMT 20 working days If the investigation is not completed within the timeline then a delay justification shall be given. 5.11 Excursion in Microbial Counts for Water Samples beyond Alert Limit-5.11.1 If count is observed higher than alert limit then the Analyst shall fill the Format.5.11.2 Authorized QA person shall allocate the unique alphanumeric identification number for the excursion.5.11.3 Intimation shall be received by Area In charge and activity based on the requirement shall be performed and mentioned in format.5.11.4 When microbial counts exceed the alert limit increase the cleaning and sanitization of the water system with double frequency till counts come to normal (if required).5.11.5 Review the results of the previous day and days before and after the observation date, to evaluate whether the observation is localized, one of case or systemic.5.11.6 Monitoring of the water system with routine frequency can be continued to provide assurance of the system.5.11.7 If there are multiple observations (i.e. more than 5) for the same loop system/same water system on a single day/multiple days then the same shall be considered as an excursion beyond action limit and the measures shall be taken up according to the action limit excursion.5.11.8 If Microbial counts are beyond alert limit for 3 consecutive days then the same shall be considered as an excursion beyond action limit and the measures shall be taken up according to the action limit excursion.5.11.9 If the microorganism recovered from any water system/loop system or water sampling location when identified is categorised as Objectionable microorganism, then the action for the entire water system/loop system shall be taken up according to the action limit excursion. 5.12 Excursion in Microbial Counts for Water Samples beyond Action Limit-5.12.1 If count is observed higher than action limit then the Analyst shall fill the Forma.5.12.2 Authorized QA person shall allocate the unique alphanumeric identification number for the excursion.5.12.3 Investigation for any possible laboratory error shall be performed if counts are observed higher than action limit along with the process level investigation (Manufacturing/Engineering investigation).5.12.4 When microbial counts exceeds the action limit, follow the action plan as given below:5.12.4.1 When the action limit is crossed then plant shall be sanitized immediately. Sampling and testing shall be done on the consecutive day of the information only after completion of sanitization activity.5.12.4.2 Whenever action limit is crossed identify the organism at least based on its morphological characteristics.5.12.4.3 In case, there are continuous alert /action level excursion and colony morphology is same as identified, then identification can be performed for only the colonies with different morphology which have not been identified earlier.5.12.4.4 Increase frequency of microbial monitoring to twice in a day for three days if for 3 consecutive days excursion above action limit is observed. The test shall be performed for the specific test parameter only for the specific location.5.12.4.5 Increase frequency of microbial monitoring to twice in a day for three days if for 5 consecutive days excursion above action limit is observed in a specific loop system or water system. The test shall be performed for the specific test parameter only for the specific location.5.12.4.6 After completion of investigation and CAPA Investigation report shall be submitted to QA for closure within a period of NMT 20 working days. If the investigation is not completed within the timeline then a delay justification shall be given in format.5.12.4.6 If any of the microbial monitoring results is not found within specified limit, stop the activities (Manufacturing/Filling/Testing) in the area.5.12.4.7 Engineering department shall be called for the corrective action.5.12.4.8 After corrective action perform the microbial monitoring of the system with increased frequency of twice in a day for three consecutive days or as per the requirement based on the contamination observed.5.12.5 Excursion in Microbial Counts beyond Specification Limit (OOS)-5.12.5.1 If OOS (Excursion of microbial counts beyond the specification limit) in Environment Monitoring/Water monitoring samples is observed below mentioned procedure shall be followed.5.12.5.2 Preliminary Laboratory Investigation shall be performed for all the OOS results / observations including the following but not limited to-Checking of results of all other samples/locations monitored on the same day in same area-Incubator temperature and conditions during the incubation of the plates/samples-Any unusual deviation during the period including power failure etc.-Training/certification record of the sampling analyst/ person incubating/transferring the plates and the person who has taken the observation.-Environment record of the day when plates were prepared in lab.-Details of preparation of the plates/media for sampling/testing purposes etc.-Presence of contamination in any of the plates observed during the day.5.12.5.3 Isolation and Identification of contaminant micro-organisms shall be performed up to species level.5.12.5.4 The source of the identified organisms shall be correlated with the in house isolate library, a probable cause of the presence of organisms shall be determined.5.12.5.5 Impact of OOS on product quality shall be assessed by site Head – QC & Head – QA.5.12.5.6 Secondary Investigation/Shop floor investigation shall be performed for all the OOS where no assignable cause is identified in the laboratory Investigation and shall include the following but not limited to-Checking of environment records for the day when exposure/sampling was done.-Checking of cleaning and sanitization activities performed for the day for the area or loop.-Checking of the qualification status of the HVAC/equipment/personnel/Water system as per the observation-Review of monitoring records for the preceding and the succeeding day and review of the trends for the area/water system.-Interrogation of the personnel's present on the day of the activity and check for any error-Interrogation of the sampling person present on the day of the activity and check for any error-Review of the training record of the personnel 5.12.5.7 Rigorous cleaning and sanitization of the equipment/area/water system shall be carried out, with a revision of the sanitization program, including selection of antimicrobial agents, application methods and frequencies.5.12.5.8 Increased surveillance of personnel practices, possibly including written procedure for aseptic methods and techniques to be followed5.12.5.9 Review of microbiological sampling methods and techniques.5.12.5.10 Additional training on gowning practices, if excursion observed for gown or glove monitoring shall be imparted.5.12.5.11 Rigorous monitoring of the area/water system with close observation shall be carried out for three consecutive days. Upon satisfactory results of 3 days monitoring the area/water system shall be used for further testing/manufacturing/filling activities.5.12.5.12 Additional testing of products/samples under impact due to the excursion can be carried out if required.5.12.5.13 The OOS investigation for the Environment monitoring samples shall be carried out in format.5.12.5.14 The OOS investigation for the Water samples and all other samples shall be carried out in format.5.12.5.15 The investigation shall be performed to determinea) The root cause of the excursion so that CAPA may be taken for remediation purposesb) Assess the impact on the affected processes and finished products where the water or the area was used.c) Product disposition decisions shall be made which shall be dependent on the factors as listed below.- Role of water/area in the product or in process material- Chemical or microbial nature of the attribute whose specification value was exceeded.- Level of product contamination by the water/area- Presence of Objectionable microorganisms- Any downstream processing of affected in process materials/products that could mitigate the OOS attribute.- Physical and chemical properties of the finished product where the water/equipment was used that could mitigate the OOS attribute.- Product administration routes and potentially sensitive/susceptible users for the product or the material.5.12.6 Excursion in Microbial Counts For Grade A and B areas in Environment Monitoring of Sterile Manufacturing areas/Sterility testing area:5.12.6.1 If the microbial counts observed in Grade A area are more than the specified limit e.g. <1 cfu/4hours for Settle Plate monitoring or <1 cfu/m3 for Volumetric Air Sampling then initiate an OOS report as per specific Format.5.12.6.2 If the microbial counts are beyond the Specification limit for all the shifts and in all continuous monitoring plates then an investigation to identify the root cause shall be done and a Secondary Manufacturing investigation shall be performed.5.12.6.3 If the microbial counts in Grade A are beyond 5 cfu/unit of measurement in any of the Environment Monitoring method (i.e. Settle Plate, Volumetric Air Sampling, Surface monitoring or Personnel Monitoring) then the activity in that specific area shall be stopped.5.12.6.4 If the microbial counts in Grade B are beyond 10 cfu/unit of measurement in any of the Environment Monitoring method (i.e. Settle Plate, Volumetric Air Sampling, Surface monitoring or Personnel Monitoring) then the activity in that specific area shall be stopped.5.12.6.5 Rigorous cleaning and sanitization of the equipment/area shall be carried out, with a revision of the sanitization program, including selection of antimicrobial agents, application methods and frequencies.5.12.6.6 Additional training on gowning practices, aseptic practices etc., if excursion observed for gown or glove monitoring shall be imparted.5.12.6.7 Rigorous monitoring of the area with close observation shall be carried out for three consecutive days/working shifts. Upon satisfactory results of 3 days/working shifts monitoring the area shall be used for further testing/manufacturing/filling activities.5.12.6.8 Additional testing of products/samples under impact due to the excursion can be carried out if required.5.12.6.9 If the microbial counts in Grade A are more than 1 to Less than 5 cfu/unit of measurement and in Grade B are more than 3 to Less than 10 cfu/unit in any of the Environment Monitoring method (i.e. Settle Plate, Volumetric Air Sampling, Surface monitoring or Personnel Monitoring) for consecutive shifts but are not exceeding 5cfu for Grade A and not exceeding 10 cfu for Grade B then the activity in that specific area shall continue with Rigorous cleaning and monitoring activity.5.12.6.10 If required, in consultation with QA the Environment Monitoring observations can be taken for the under incubation plates (i.e. Plates those are under incubation and have completed a minimum of 3 days of incubation). The activity shall be dealt as per CSOP on Handling of Deviations CSOP/2013/003.5.12.6.11 If consecutive excursions from the specified limits are observed then Rigorous cleaning, monitoring activity shall be taken after the stoppage of the testing/manufacturing/filling activity.5.12.6.12 The root cause for the excursion shall be determined and appropriate actions shall be decided.5.12.6.13 If the excursions in the areas are one of case and not repeated in subsequent shift then routine cleaning and monitoring activities shall continue, the root cause of the excursion shall be determined.5.12.6.14 If there are multiple observations (i.e. more than 2) for the same room/area (including Grade A and B) on a single day/multiple days then rigorous cleaning, monitoring activity shall be taken after the stoppage of the testing/manufacturing/filling activity.5.12.6.15 If the microorganism recovered from any of the location and when identified is categorised as Objectionable microorganism, then rigorous cleaning, monitoring activity shall be taken after the stoppage of the testing/manufacturing/filling activity. 5.13 Excursion in Microbial Counts of Personnel Monitoring beyond Specification Limit-5.13.1 If count is observed higher than specification limit then initiate an OOS and perform investigation as mentioned below.5.13.2 Investigation for any possible laboratory error shall be performed if counts are observed higher than specification limit along with the process level investigation in defined format.5.13.3 The investigation shall include the following but not limited to-Evaluate possible operator impact on product and the area-Review current environmental monitoring data and sterility test data-Review preparation and expiry dates for disinfectants used on gloves-Identify all morphologically unique isolates(human v/s environment)-Interview operator for potential cause and retrain or re qualify operator.-Evaluate training of operator-Review sanitization and disinfection records of area-Review closed circuit video (if applicable)-Review previous gowning data for the operator and other operators on the same day.-Review the data of the same operator on the subsequent shifts/days, if the operator is routinely performing the work in the sterile manufacturing area. 5.13.4 In case of microbial count of finger dabs/gown monitoring of personnel exceed the action or specification limit continuously then disqualify the personnel for entry into Sterile Manufacturing area/Sterility Testing area and shall be only allowed after complete personnel qualification as employed for an initial personnel qualification of a personnel.5.13.5 In case of microbial count of finger dabs/gown monitoring of personnel show excursion above the specification limit only for a day/shift then5.13.5.1 Train the personnel for clean room practices.5.13.5.2 Increase the frequency of personnel monitoring to twice in a day for three consecutive days/shifts for Sterile Manufacturing areas /Sterility Testing area for that specific personnel if the person is performing activities in the area routinely. 5.13.5.3 If still the counts of specific personnel are showing excursion, the person shall not be allowed to perform any aseptic handling in the area and shall be only allowed after complete personnel qualification as employed for an initial personnel qualification of a personnel. 5.14 Laboratory Investigation-Phase I (Primary Laboratory Investigation) for OOS in any of the parameter:5.14.1 Interrogate the analyst/operator for all details of procedure he/she followed, which will give an idea of his/her understanding of the procedure and the probable cause, if any, of the OOS.5.14.2 Laboratory Investigation (Primary Laboratory Investigation) shall be performed for all the OOS results / observations. First phase of investigation should include as initial assessment of the accuracy of the laboratory’s data. Whenever possible, this should be done before test preparation is discarded.5.14.3 Laboratory Investigation shall include but not limited to :-5.14.3.1 Error in handling or storage of media.5.14.3.2 Error in following the Procedure of monitoring.5.14.3.3 Error during sterilization of media and accessories used in monitoring.5.14.3.4 Error during observation5.14.3.5 Error in calculation.5.14.3.6 Use of non calibrated instruments (e.g. Air sampler)5.14.3.7 Lack of training / knowledge.5.14.3.8 Use of expired or old media5.14.3.9 Improper storage and handling of media or media plates.5.14.3.10 Inadequate incubation of plates after monitoring.5.14.3.11 Others if any.5.14.3.12 Perform the isolation and identification of contamination from the OOS sample.5.14.3.13 Identification of contaminant micro-organisms shall be performed up to species level.5.14.3.14 Perform the identification of colonies observed with new morphology from water, environment, and personnel monitoring samples during the period of sampling, analysis and incubation of OOS sample.5.14.3.15 Check the samples analyzed on same day, using same or different lot of media, incubated in the same incubator, using the same stock of culture concentrations for the positive control and growth promotion test.5.14.3.16 Check the weight of media, pH of media, sterilization cycles of the media and glass wares, storage of the sterilized media and glass wares.5.14.3.17 Check the training and certification status of microbiologist.5.14.3.18 Check the glassware management (Washing, sterilization and storage) used for the testing purpose.5.14.3.19 Check media receipt, qualification, usage, preparation, sterilization, storage & hold time limits against the procedure/validations.5.14.3.20 Check the cleaning and sanitization status of Analytical / working area (media preparation area, analytical area, incubation area, LAF etc.)5.14.3.21 Correlate the isolated contaminant with micro-organisms in the culture library.5.14.3.22 Check equipment / instrument Qualification, Validation, calibration and cleaning status. 5.14.3.23 Check environment monitoring record (temperature, humidity, pressure differential, settle plate count, active air sampling count, surface monitoring, particle count and personnel monitoring).5.14.3.24 Check for any power failure during sampling, analysis, sterilization and incubation. Check for any abnormal observation during sampling, analysis, sterilization and incubation.5.14.3.25 Check status of positive controls, negative controls & product positive controls.5.14.3.26 Check results / observations of other analysis performed on same day by same microbiologist for sample under question and also check for the observation / results of test performed using same area by other microbiologist.5.14.3.27 Check the report for appropriate calculations.5.14.4 For Sterility Test Laboratory investigation also check the following:5.14.4.1 Review the reports of a week prior to and after the day of test.5.14.4.2 Review the trends of last 2 months for any upward trend in microbial counts of the area.5.14.4.3 Check for the non viable particulate monitoring for any anomalies.5.14.4.4 Verify the results of negative product control test of the particular day.5.14.4.5 Review the sterility test report and verify whether all media and sterile materials are within expiration dates.5.14.4.6 Review the preparation record of all media, rinsing fluids and diluents used in the test.5.14.4.7 Verify the containers for sterility check if they are still under incubation or if any other similar lot are available for used.5.14.4.8 Review the differential pressure, temperature and relative humidity records for the day of test and nearby days for any excursion observation.5.14.4.9 Review the instrument usage and maintenance logs and verify if any activities were performed that may have impact on the results.5.14.5 Impact of OOS on product quality shall be assesed by Head – QC & Head – QA or their Designee.5.14.6 Head – QC/Designee shall assess the data generated from the investigation to identify the probable cause.5.14.7 If an assignable cause is identified for OOS result, Head – QC shall record details in Format.5.14.8 Following are the actions to be completed:5.14.8.1 Details of assignable cause.5.14.8.2 Corrective actions to be taken.5.14.8.3 Repeat test on the remaining sample (Sample A) if sample is available or on the Original Sample.5.14.8.4 If this sample portion is not available, or is spoiled, use previously collected sample for analysis. If this also is not available re-sampling may be performed with prior approval of QA.5.14.8.5 If the results found passing, invalidate the OOS results. Report the repeat test results and close the OOS with justification.5.14.8.6 Preventive actions to be taken for future including training of concern personnel.5.14.8.7 Disposition action for sample / batch under investigation (with justification) shall be provided.5.14.8.8 Evaluate and determine if a corrective action is require, if yes, describe the corrective action and preventive action.5.14.8.9 Ensure that the corrective action if require is implemented at the earliest and in timely manner.5.14.8.10 If the assignable cause is found to be due to analyst error, analyst shall be re trained and re qualified (if required) for the analysis.5.14.8.11 All the results of analysis performed by the analyst during the period shall be thoroughly evaluated for the results.5.14.8.12 If required, reanalysis shall be performed by other qualified analyst.5.14.8.13 If the results for stability samples do not conform, check for the expiry for product. Check for the storage condition, previously generated stability data, previous related OOS investigation and product related results.5.14.8.14 If the results found failing QA person shall perform extended investigation (Full Scale OOS investigation-Phase II). 5.15 Full scale OOS Investigation/Phase II Investigation:5.15.1 If assignable cause is not identified in laboratory investigation, proceed as below:5.15.2 The Phase II investigation shall be initiated within three working days, after conclusion of Phase I (Laboratory investigation) is completed and approved.5.15.3 Extended Investigation shall be performed by using investigation tool e.g. Fish bone or Ishikawa diagram or using tools of quality risk assessment.5.15.4 QA person shall perform Extended Investigation / Failure Investigation.5.15.5 Investigation shall cover following points but not limited to:5.15.5.1 Perform the extended investigation at ware house for receipt, sampling, storage and dispensing of material.5.15.5.2 Perform investigation in manufacturing, packing and holding of drug substance and drug products.5.15.5.3 During investigation cover personnel, machine, material, environment and methods.5.15.5.4 Include the manufacturing process related contamination and cross contamination issues during investigation.5.15.5.5 If investigation does not reveal manufacturing error and data form repeat analysis shows the original OOS result arise from non assignable cause, it can be concluded that OOS is not representative of the batch.5.15.5.6 Whenever required an appropriate CAPA can be taken to avoid the recurrence.5.15.5.7 Perform the Full scale OOS Investigation-Phase II investigation. 5.16 Microbial Enumeration Test and Test for Specified microorganisms- (Full Scale OOS Investigation) Phase II investigation:5.16.1 If assignable cause is not identified in laboratory investigation, proceed for Manufacturing process related investigation:5.16.2 Scope of following investigation is for In-process tests, stability samples and finished product analysis or material processed in manufacturing area.5.16.3 Check Environmental monitoring records (temperature, humidity, pressure differential, settle plate count, active air sampling count, particle count, personal monitoring, surface monitoring), especially for the day of manufacturing / processing.5.16.4 If one or more of these analytical activity is not carried out on the day of manufacturing / processing, review previous / last records / history for that test for that area / location.5.16.5 Check Cleaning & Sanitization record for the area.5.16.6 Check equipment qualification, validation, calibration, cleaning and sanitization record.5.16.7 Check for Operators error (training / any unusual operation carried out).5.16.8 Check raw material analysis records.5.16.9 Check for any incidence or deviation during the manufacturing activity.5.16.10 Impact of OOS on product quality shall be assessed by Head – QA and QC or Designee.5.16.11 If assignable cause is not identified repeat the analysis by re-sampling with larger sample pool (Twice the original sample if required)5.16.12 The repeat testing shall be performed only for the parameter which is showing an OOS/non complying result.5.16.13 Repeat testing to be performed in duplicate with same sample quantity by same and other microbiologist by following the same procedure of MET and TSM.5.16.14 If still sample fails, reject the batch. This applies even if one of the results of duplicate analysis is failing.5.16.15 Further decision on the disposition of batch / material shall be taken by Head QA, if required in consultation with Corporate Quality 5.17 Microbial Enumeration Test and Test for Specified microorganisms- (Full scale OOS Investigation) Phase II investigation for Raw/Packing Materials analysis:5.17.1 If assignable cause is not identified in laboratory investigation, proceed for extended investigation.5.17.2 Further investigation shall be carried by Head QA, Head QC or Designee in coordination with Vendor or if required in consultation with Corporate Quality.5.17.3 If assignable cause is not identified repeat the analysis by re-sampling the batch with larger sample pool (Twice the original sample if required).5.17.4 The repeat testing shall be performed only for the parameter which is showing an OOS/non complying result.5.17.5 The repeat analysis shall be joint analysis with vendor or analysis in presence of vendor. 5.17.6 If feasible the 1st Microbiologist (Microbiologist who performed the analysis earlier) shall perform joint analysis with vendor. The procedure for joint analysis shall be similar to that of initial analysis.5.17.7 If still sample fails, reject the batch. This applies even if one of the results is failing in joint analysis.5.17.8 Further decision on the disposition of batch/material shall be taken by Head QA, if required in consultation with Corporate Quality 5.18 Water Analysis (Full scale OOS Investigation)- Phase II investigation:5.18.1 If assignable cause is not identified in laboratory investigation, proceed for Full Scale OOS Investigation. Inform Head QA/QC/Manufacturing/Engineering etc.5.18.2 Head Manufacturing shall take decision to quarantine the batches manufactured during the period starting from sampling of sample under question till the closure of the investigation.5.18.3 Scope of this investigation includes Potable water/Treated water/DM water/Purified water/Water for Injection and Pure Steam.5.18.4 Check Environmental monitoring records (temperature, humidity, pressure differential, settle plate count, active air sampling count, and particle count) if the excursion observed is in the Manufacturing or Microbiology Lab.5.18.5 If one or more of these analytical activity is not carried out on the day of manufacturing/processing, review previous/ last records/ history for that test for that area/location.5.18.6 Compare the cultural and microscopic characters of organism(s) in question to most common contaminant (In-house Isolate). If new organism isolated then identify it.5.18.7 Check cleaning & Sanitization record for the sampling area.5.18.8 Check for error in sampling or any unusual observations during sampling.5.18.9 Check water system validation, calibration, cleaning, and sanitization record trend data.5.18.10 Interrogate the personnel's present on the day of the activity and check for any error.5.18.11 Check for operator’s error (training / any unusual operation carried out).5.18.12 Review upstream water treatment systems (e.g. Carbon beds used to remove chlorine from Raw water).5.18.13 Examine the microbial count data for other samples or sites in the system -port contamination vs. System contamination.5.18.14 Review efficacy if sanitization procedure and schedule.5.18.15 Inspect system preventive maintenance records. Evaluate impact on product.5.18.16 Inspect system for dead lags, proper sloping, and proper sample port design and location.5.18.17 Review data for generation and distribution system for potential trends.5.18.18 Review data for the flow rate, pressure and vent filter integrity wherever used.Verify integrity of sample collection and testing procedures (if required).5.18.19 If assignable cause is not identified, inform Head –Water Plant / Manufacturing/ Engineering to proceed for corrective action.5.18.20 Appropriate and applicable corrective actions may include but not limited to;5.18.21 Rigorous cleaning and sanitization of sampling area5.18.22 Water system sanitization.5.18.23 Circulation loop sanitization.5.18.24 Regeneration of water system.5.18.25 Revision of the sanitizing agent, selection application methods and frequencies if required.5.18.26 Increased surveillance of personnel practices, possibly including written procedure for aseptic methods and techniques to be followed.5.18.27 Review of microbiological sampling methods and techniques.5.18.28 Impact of OOS on product quality shall be assessed by Head – QA and QC.5.18.29 Once the corrective action is taken, analyze the sample (sampling point with OOS results / observations) for 3 days consecutive monitoring.5.18.30 The repeat testing shall be performed only for the parameter which is showing an OOS/non complying result.5.18.31 The analysis may be performed by available Microbiologist. Efforts shall be made that Microbiologist involved in initial testing (OOS results) shall contribute to maximum extent.5.18.32 If all 3 days consecutive samples passes. The OOS is closed with summary.5.18.33 In case of 2nd and 3rd day samples are failing take corrective actions and repeat monitoring till satisfactory results / observations for three consecutive monitoring (days) with QA permission.5.18.34 In case the point(s) fails repeatedly despite of corrective action, point specific corrective and preventive measures shall be considered by Head – QA, Manufacturing, Engineering and other concerned.5.18.35 Additional testing of products/samples under impact due to the OOS shall be carried out if required. 5.19 Environmental Monitoring (Full scale OOS Investigation)- Phase II investigation :5.19.1 If assignable cause is not identified in laboratory investigation, proceed for Full scale OOS Investigation.5.19.2 Scope of this investigation includes settle plate monitoring, active air sampling, swab sampling, contact plating results and compressed air, nitrogen sample monitoring results.5.19.3 Perform the identification if the counts which exceed specification limit as per SOP.5.19.4 Check for error in sampling or any unusual observations during monitoring.5.19.5 Check Environmental monitoring records (temperature, humidity, pressure differential).5.19.6 Review previous / last records / history for that test for that area / location.5.19.7 Compare the cultural and microscopic characters of organism(s) in question to most common contaminant (In-house Isolate).5.19.8 Check cleaning & sanitization record for the area.5.19.9 Check the qualification status of the HVAC/equipment/personnel as per the observation.5.19.10 Review the monitoring records for the preceding and the succeeding day and review of the trends for the area.5.19.11 Interrogate the personnel's present on the day of the activity and check for any error.5.19.12 Review the training record of the personnel5.19.13 If assignable cause is not identified, inform Head – Manufacturing/ Engineering to proceed for corrective action.5.19.14 Appropriate and applicable corrective actions may include but not limited to.5.19.15 Rigorous cleaning and sanitization of the area.5.19.16 Cleaning and sanitization of equipment / instruments.5.19.17 Increased surveillance of personnel practices, possibly including written procedure for aseptic methods and techniques to be reviewed.5.19.18 Review the microbiological sampling methods and techniques.5.19.19 Additional training on gowning practices, if excursion observed for gown or glove monitoring shall be imparted.5.19.20 Other (based on observations and results / observations) action if required shall be taken.5.19.21 Impact of OOS on product quality shall be assessed by Head – QA and QC.5.19.22 Once the corrective active is taken, monitor the sample (sampling point with OOS results / observations) for 3 consecutive monitoring (days).5.19.23 The repeat sampling/ testing shall be performed only for the parameter which is showing an OOS/non complying result.5.19.24 The analysis may be performed by available Microbiologist. Efforts shall be made that microbiologist involved in initial testing (OOS results) shall contribute to maximum extent.5.19.25 If all three consecutive samples passes. The OOS is closed with summary.5.19.26 In case sample fails any day during close monitoring (three consecutive days) repeat corrective actions and monitoring till satisfactory results / observations for three consecutive monitoring (days) with QA permission.5.19.27 In case the point(s) fails repeatedly despite of corrective action, point specific corrective and preventive measures shall be considered by Head – QA, QC, Manufacturing, Engineering and other concerned.5.19.28 Additional testing of products/samples under impact due to the OOS can be carried out if required. 5.20 Bacterial Endotoxin Testing (Full Scale OOS Investigation)-Phase II investigation :5.20.1 If assignable cause is not identified in laboratory investigation, proceed for Manufacturing process related investigation as per the below but not limited to :5.20.2 Check Cleaning & Sanitization record for the area.5.20.3 Check equipment qualification, validation, calibration, cleaning and sanitization record.5.20.4 Check for Operators error (training / any unusual operation carried out).5.20.5 Check raw material analysis records.5.20.6 Impact of OOS on product quality shall be assessed by Head – QA and QC.5.20.7 If assignable cause is not identified repeat the analysis by re-sampling.5.20.8 The repeat testing shall be performed only for the parameter which is showing an OOS/non complying result.5.20.9 Repeat testing to be performed in duplicate with same sample quantity by same and other microbiologist by following the same procedure.5.20.10 If still sample fails, reject the batch. This applies even if one of the results of duplicate analysis is failing.5.20.11 Further decision on the disposition of batch / material shall be taken by Head QA, if required in consultation with Corporate Quality. 5.21 Sterility Testing (Full Scale OOS Investigation)-Phase II investigation :5.21.1 If evidence of microbial growth is found, the product to be examined does not comply with the test for sterility, unless it can be clearly demonstrated that the test was invalid for causes unrelated to the product to be examined i.e. A clear failure due to laboratory reasons is identified.5.21.2 The test may be considered invalid only if one or more of the following conditions are fulfilled:-The data of the microbiological monitoring of the sterility testing facility show a fault.-A review of the testing procedure used during the test in question reveals a fault.-Microbial growth is found in the negative controls. 5.21.3 Identify the microorganism isolated from the test by using Strain typing method of identification (by genus and species level identification) or molecular fingerprinting (as feasible).5.21.4 Preserve tube/sample with results/observations in question.5.21.5 Subculture the growth on suitable media (e.g.: Bacterial or fungal growth promoting culture media).5.21.6 Record cultural and microscopic observations. Perform the identification up to species/ genus level of contaminant.5.21.7 If the growth is observed in FTGM perform sub culturing in duplicate incubate one set in aerobic conditions and one set in anaerobic conditions.5.21.8 If the contaminant is slow growing or does not grow on sub culturing to solid media use other methods to subculture and identify the organism.5.21.9 Identify the colonies from sterility testing area environmental and personnel monitoring plates sampled on the day of test if available or of subsequent days to determine the similarities.5.21.10 Determine the reason for the fault based on the source of microorganism either material or the technique followed in conducting the sterility test procedure5.21.11 Simultaneously proceed for Manufacturing/process Investigation5.21.12 Scope of following investigation is for in-process tests, stability samples and finished product analysis or material processed in manufacturing area.5.21.13 Check Environmental monitoring records (temperature, humidity, pressure differential, settle plate count, active air sampling count, particle count, drain monitoring), especially for the day of manufacturing/processing.5.21.14 If one or more of these analytical activity is not carried out on the day of manufacturing, review previous records for that test for that area/location.5.21.15 Compare the cultural and microscopic characters of organism(s) in question to most common contaminant ( In-house Isolate)5.21.16 Check cleaning & Sanitization record for the area5.21.17 Equipment validation, calibration, cleaning and sanitization and sterilization record. Review sterilization process. 5.21.18 Check for operators error (training / any unusual operation carried out)5.21.19 Results/observations of in-process tests (if performed)5.21.20 If the test is declared to be invalid, repeat the test with the same number of units as in the original test.5.21.21 If no evidence of microbial growth is found in the repeat test, the product examined complies with the test for sterility.5.21.22 If microbial growth is found in the repeat test, the product examined does not comply with the test for sterility. This applies even if one of the result is failing in another microbiologist5.21.23 Further decision on the disposition of batch/material shall be taken by Head QA, if required in consultation with Corporate Quality.5.21.24 An extensive impact evaluation shall be done in case Sterility failure is observed and all the batches under a single campaign shall be tested.5.21.25 If the impact is for a large span the evaluation of batches from last successful process simulation study (media fill study) shall be taken under consideration. 5.22 Failure Investigation if growth is observed after Preincubation:5.22.1 The preincubation of the media shall be performed prior to the usage for the various testing purposes.5.22.2 If microbial contamination for a lot is less than 3% then the plates/tubes with contamination shall be discarded and the remaining good plates/tubes shall be used for the testing purposes and the discard quantity shall be recorded in the media reconciliation logbook.5.22.3 If microbial contamination in a preincubated lot is observed more than 3% but less than 10% of the prepared lot then the same shall be investigated. The plates/tubes with contamination shall be discarded and the remaining good plates/tubes shall be used for the testing purposes and the discard quantity shall be recorded in the media reconciliation logbook.5.22.4 If contamination in a preincubated lot is observed for more than 10% of the prepared lot then the entire lot shall be discarded and the reason shall be investigated.5.22.5 The investigation shall be completed within 7 working days from the date of initiation of the investigation. If investigation is not completed within the timeline then a delay justification shall be initiated.5.22.6 The Report shall be submitted back to QA for record and reference purposes.5.22.7 Following parameters shall be evaluated but not limited to the following:5.22.7.1 Review all the parameters from preparation, sterilization, dispensing and preincubation.5.22.7.2 Determine the most probable root cause for the failure.5.22.7.3 The reason could be analyst error during handling/preparation/dispensing of the media.5.22.7.4 If the reason identified is analyst error then identify the particular colonies and study the characteristics.5.22.7.5 If colony observed is one of the in house isolates, check the whole lot of media tubes or plates.5.22.7.6 If many of the media containers are showing growth repeatedly check whether the steam sterilizer is in calibrated state during sterilization of media.5.22.7.7 Check for the loading configuration/pattern in which most of the failures related to preincubation are observed.5.22.7.8 Check for proper functioning of steam sterilizer. If required, re-validate the instrument.5.22.7.9 Check for the various failures, dispensed earlier or concurrently.5.22.7.10 Check whether the failures are observed only when the media is dispensed by a particular analyst.5.22.7.11 Thoroughly evaluate the samples analyzed using that particular media (if the media is used).5.22.7.12 If any failure is more than 10% and the media has been used for any sample analysis prior to preincubation, disregard the analysis and re analysis shall be carried out of those samples using fresh and approved lot of media by initiating a Deviation as per SOP on Handling of Deviation 5.23 Handling and Investigation of Out of Limits Results in Non Viable Particle Monitoring:5.23.1 On obtaining any out of limit results during non viable monitoring, proceed as below but not limited to :5.23.2 Initiate an OOS record for the observation made.5.23.3 Check the instrument is operating properly and any disturbance or changes in room conditions are observed.5.23.4 Check for the activities performed during the sampling (specifically for particle or aerosol generating or disturbance to the particle counter probe) performed around the sample location during the time of out of limit results and evaluate if it has any impact on the reported results.5.23.5 Verify that the instrument used was within calibration and testing performed as per procedure.5.23.6 If appropriate, perform the zero count of the particle counter by attaching the filter on the sampling nozzle.5.23.7 Clean the area if required and resample the location after the conditions are restored and verify the results.5.23.8 Record the noted observation and report.5.23.9 If the results of resample are conforming to the limits, then no further action is required.5.23.10 If the results are still non conforming stop the activities in that specific area, until resolution is obtained.5.23.11 Review the trend for the sample location/room in question and results of other sample locations performed on the day.5.23.12 Review department cleaning logs, room differential pressure records, number for personal in the room at the time of testing, number of equipments and their operation status and other activities for any discrepancies.5.23.13 Contact Engineering department and review logs for any discrepancies in the functioning and maintenance of HVAC/LAF/BSC etc. as per the location and other systems or any maintenance activities undertaken.5.23.14 Evaluate the information gathered and determine if it has an impact on the results observed.5.23.15 Based on the information gathered, evaluate the actions to be performed and perform re-sampling of the concerned location or room as per Investigation report and proceed accordingly.5.23.16 If the resample results conform to limits then no further action is required.5.23.17 If the resample results do not conform to the limits, then carry out further investigation for determining the root cause against the OOS.5.23.18 Following activities can be performed to determine the root cause:-Rigorous cleaning of area-Air Velocity verification of HEPA filters in the area.-HEPA filter integrity testing-Air flow studies (if required) 5.24 General:5.24.1 Review, adequacy, applicability, implementation, accuracy and specificity of SOPs shall also be considered during investigation.5.24.2 The investigation is not limited to above mentioned procedures. If required investigations can be initiated for other tests as well if required.5.24.3 If for a test alert limit is not fixed or not defined then consider the action limit for the acceptance criteria.5.24.4 Whenever specification limits are not mentioned or the results are for information purposes only then the investigation is not required.5.24.5 Wherever and whatever is identified as probable/assignable cause, the part/activity shall be revised/modified/upgraded.5.24.6 Wherever possible and applicable results / observations of related samples shall be considered in full scale OOS investigation. This may include pre and post samples.5.24.7 Retesting and investigation may be focused to a particular test(s). e.g.: one of the test for specified microorganisms, only evaluation of Total aerobic microbial counts/Total viable aerobic counts or Total yeast and mold counts. Such decision shall be made by Head- QC with justification, in coordination with Head- QA.5.24.8 Similar procedure can be used with required customization for microbiological test not outlined in these procedures.5.24.9 Such procedure shall be checked by Head – QC and approved by Head – QA.5.24.10 In either of cases Training and re-training shall be considered by Head –QC & Head – QA , wherever necessary and applicable 5.24.11 Laboratory investigation except microbial identification shall be completed within a period of NMT 7 working days.5.24.12 Closure of complete OOS Investigation shall be performed within a period of NMT One month (30 working days).5.24.13 Closure of complete OOS Investigation for the Sterility Test failure shall be performed within a period not more than 45 working days.5.24.14 In case extension of investigation is required justification for the same shall be duly approved from QA.5.24.15 NOTE: Excursion/OOS in Bioburden evaluation of coating solutions hold time study samples, cleaned and uncleaned equipment hold time study and samples other than routine samples shall be investigated but the study shall be considered aborted and an evaluation based on the results and investigation shall be drawn.5.24.16 Based on the results the time line/hold time period shall be evaluated and finalized.5.24.17 Excursion/OOS observed in samples sent to Contract testing laboratory shall be logged within 24 hrs after the receipt of the intimation from the laboratory.5.24.18 The laboratory shall be instructed to perform the relevant preliminary laboratory investigation and share the details within 7 working days of the notification.5.24.19 Full scale OOS Investigation-Phase II investigation shall be initiated upon receipt of the laboratory investigation. 5.25 TRENDING OF THE DATA DEVIATIONS5.25.1 Trending of the following data deviations observed shall be prepared by Microbiologist quarterly and annually.
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