Auditing the Microbiology Laboratory

Auditing the Microbiology Laboratory

Introduction 

This training will provide a basic understanding of an audit of a typical Microbiology Laboratory.

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We have divided this training into two sections:

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I.

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II. Useful, Often Relevant Audit Questions

Major Areas of Audit in the Micro Lab

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I. Major Areas of Audit in the Microbiology Laboratory 

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As a QC lab, the Micro dept. must comply with the same basic GMP regulations promulgated for the Analytical Chemistry Lab. With this in mind, we have adopted the standard – 8 major areas in a lab audit – described ~ a year ago in GQAC training on Auditing the Analytical Chem Lab. 3

Major areas of audit in the microbiological laboratory As a reminder, the major areas of audit in a QC lab are: 1. 2. 3. 4. 5. 6. 7. 8.

Sample Control Employee Training Reference Standards Equipment and Instruments Reagents and Media Recordkeeping and Documentation Laboratory Controls Method Validation

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1. Sample Control 

Just like with samples coming into the Analytical Chem Lab, samples coming into the Micro Lab: 

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Must have sample records that show chain-ofcustody. Records can be manual, e.g., forms or logbooks, or electronic, e.g., LIMS (laboratory information management system). Must be stored in an area that maintains their quality. This includes areas that are properly identified, clean and orderly, and is adequate to prevent mix-up and contamination from other samples, from chemicals and reagents, and from spillage. 5

Sample Control Audit Questions 1. 2.

3.

4.

5.

6.

Ask how Micro samples are logged in and stored.

Does the sample log book (or other record) provide spaces for who delivered the sample and who then took it for testing (chain of custody)? What type of samples might be temporarily stored while awaiting testing? What method validation or compendial ref supports the sample storage conditions (e.g., water)? What site SOP governs what happens when a water or an EM sample time point is missed? (should be a deviation). If LIMS is used for tracking all samples and activities, check if pen raw data precedes computer and whether the former is properly retained. 6

(Water) Sample Control Audit Questions 1. 2.

3.

4.

5.

6.

7.

Ask how water samples are drawn; compare to site SOP. Is the chemistry sample collected before the Micro (i.e., if a spray disinfectant is used on the sample port)? If any sampling sites are also points of use (POU) for Mf’g, how comparable are the Micro sampling and Mf’g cleaning/rinsing/use of the same POU’s? Does the sample record contain time sample taken, sampler’s name, sample site, time sample delivered to Lab? Are water-sampling bottles reused with a validated sterilization cycle and a proper storage/protection in between? Is the expiration date on those stored water sampling bottles supported by a study (or any data)? If there is a maximum number of hours that may elapse between sampling and bacterial enumeration testing, is the actual time or hour of sampling recorded along with the date? 7

(Water) Sample Control Audit Questions 8.

9.

10.

11.

12.

Ask for the most recent enumeration data of a specific critical water POU (should contain or refer to date/time sample taken, date/time plated and put in incubator & date/time out of incubator + incubator ID+ lot # of media used). What media is used to test water for counts? (If that water goes into a European-marketed product, then R2A Media). Ask to see growth promotion testing of the media (some companies require a water system isolate to be included). When is a colony identified? Ask for the SOP covering this decision (should be obtainable from within the Lab itself— workers need proximity to their SOPs). Ask to see total viable count & the organisms identified in the WFI loop (for all POUs) for past 18 mos.

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2. Employee Training 

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Employee training includes the basics needed for every pharmaceutical employee, i.e., a combination of education, training, and experience to do his or her job. The core educational background of the microbiology staff must be in microbiology or a closely related biological science. cGMP training and task training are provided before performing the task, and with experience comes more complex testing, and specific organism identifications.

In the Microbiology Lab, much of the task training is by Technique as opposed to being by Product. The training program should include an established training curricula specific to job functions, and periodic performance assessments to verify ongoing competency in core activities, e.g., hygiene, plating, aseptic technique, handling test failures.

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Analyst Training Audit Questions 1. 2.

3.

4.

Ask to see the Lab’s org. chart. Has cross-training created sufficient designated back-ups for critical activities in the Lab (or even for reviewing analysts’ results)? Ask to see the training curricula for each unique Lab position. Determine the most recent effective date for a change to a Micro SOP, then examine training records for updated training on the new revision.

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Ask to see the Microbiology OOS procedure.

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Ask to see the OOSs in Micro for the past 18 mos.

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Can patterns be seen in tests or analysts associated w/ OOSs, and if so, what CAPAs have followed? 10

3. Reference Standards 

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The microbiology laboratory shares the same requirements that apply to the Analytical laboratory; it must also ascertain that the reference standards used are of the highest quality for the required tests Noteworthy standard requirements include those for:

- Standards which need to be frozen at extremely low temperatures, including microbiological cultures. Check procedure to handle these standards (e.g., use of liq N2). - The USP Endotoxin RSE has a defined potency of 10,000 USP Endotoxin Units (EU) per vial. The first dilution of the concentrate may not be stored in a refrigerator for more than 14 days for use in subsequent dilutions. Further dilutions may not be stored w/o supporting data (risk of lost activity via adsorption to container)

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3. Reference Standards 

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Biological Indicator (BI): is a challenge organism, usually as a spore, which can be characterized by its population and D-value. The D-value is the number of minutes (at defined conditions of steam, gas, or radiation) required to achieve a 1 log reduction on the total number of defined organisms. Each BI is tested by the Micro lab or an approved contract lab to confirm the vendor’s labeled bacterial population and, less frequently, D-value. BIs are placed in selected locations in sterilizing equipment during respective qualifications. To pass qualification, the sterilizer must show a 106 reduction in number of organisms after exposure at worst case (less time than in routine operations) and at prescribed pressure, BI spore population and resistance (D-value). See later section on audit questions, which explains importance of D-value.

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3. Reference Standards 

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Microbial cultures are delicate standards. Procedures should specify careful handling instructions. Preparation and resuscitation of cultures should follow the instructions of the supplier or a validated, established method. USP recommends using the "SeedLot" technique for storage of stock cultures, i.e., using working cultures and never returning unused passages back to original stock. In addition, there should be an established maximum number of passages (5 or less), and maximum storage time for working cultures. Cultures for use in compendial tests should be acquired from a national culture collection, in frozen, freeze-dried, on slants, or in ready-to-use forms. Confirmation of the purity and the identity should be performed prior to its use in quality control testing. Ready-to-use cultures may require additional confirmation of inoculum size.

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Biological Indicator Audit Questions

1.

What BI’s are purchased by the site?

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Ask to see the incoming QC test SOPs for all of them.

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4.

5.

Is the bacterial population and purity confirmed for every supplier lot of BI?

Is the D-value >= 1.5 min for 121oC steam sterilization? (required by AAMI, ISO, and USP ) Has the D-value claimed by the supplier ever been verified by a qualified lab with a BIER (biological indicator evaluator resistometer) Vessel per ANSI/AAMI ST44 or USP ? If ―no‖, ask how the site knows D >= 1.5 min 14

Biological Indicator Audit Questions (cont’d) 6.

If accepted on certificate of analysis, what BI supplier quality assurance has been established? Ask to see file. Supplier should be ―approved.‖

7.

Read the BI vendor’s use instructions, then look for data on elapsed time between cycle exposure and incubation.

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Purchased Cell Cultures 1.

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When purchasing microorganisms from a national culture collection, what incoming QC tests are run for identity and purity? Is the ID done via genotypic analysis? How are the # of passages of working cultures tracked, and what is the maximum # permitted (PIC/S says NMT 5 passages for cutures used in pos. ctls of sterility tests)? Ask to see the records of subculturing a purchased organism. How long can a working culture be used (