Where a container is offered as a pharmacy bulk package, the label shall (a) state prominently “Pharmacy Bulk Package—Not for Direct Infusion,” (b) contain or refer to information on proper techniques to help ensure safe use of the product, and (c) bear a statement limiting the time frame in which the container may be used once it has been entered, provided it is held under the labeled storage conditions.

CSPs compounded under all the following conditions are at a low risk of contamination.

When CSPs are compounded aseptically under Low-Risk Conditions and one or more of the following conditions exists, such CSPs are at a medium risk of contamination.

CSPs compounded under any of the following conditions are either contaminated or at a high risk to become contaminated.

Commercially available sterile fluid culture media, such as Soybean–Casein Digest Medium (see Sterility Tests 71), shall be able to promote exponential colonization of bacteria that are most likely to be transmitted to CSPs from the compounding personnel and environment. Media-filled vials are generally incubated at 20 to 25 or at 30 to 35 for a minimum of 14 days. If two temperatures are used for incubation of media-filled samples, then these filled containers should be incubated for at least 7 days at each temperature (see Microbiological Evaluation of Clean Rooms and Other Controlled Environments 1116). Failure is indicated by visible turbidity in the medium on or before 14 days.

The licensed healthcare professionals who supervise compounding shall be responsible for determining that the selected sterilization method (see Methods of Sterilization under Sterilization and Sterility Assurance of Compendial Articles 1211) both sterilizes and maintains the strength, purity, quality, and packaging integrity of CSPs. The selected sterilization process is obtained from experience and appropriate information sources (e.g., see Sterilization and Sterility Assurance of Compendial Articles 1211)—and, preferably, verified wherever possible—to achieve sterility in the particular CSPs. General guidelines for matching CSPs and components to appropriate sterilization methods include the following:

Dry heat depyrogenation shall be used to render glassware or containers such as vials free from pyrogens as well as viable microbes. A typical cycle would be 30 minutes at 250. The description of the dry heat depyrogenation cycle and duration for specific load items shall be included in written documentation in the compounding facility. The effectiveness of the dry heat depyrogenation cycle shall be verified using endotoxin challenge vials (ECVs). The bacterial endotoxin test should be performed on the ECVs to verify that the cycle is capable of achieving a 3-log reduction in endotoxin (see Sterilization and Sterility Assurance of Compendial Articles 1211 and Bacterial Endotoxins Test 85).

Maintaining the sterility and cleanliness (i.e., freedom from sterile foreign materials) of critical sites is a primary safeguard for CSPs. Critical sites are locations that include any component or fluid pathway surfaces (e.g., vial septa, injection ports, beakers) or openings (e.g., opened ampuls, needle hubs) exposed and at risk of direct contact with air (e.g., ambient room or HEPA filtered), moisture (e.g., oral and mucosal secretions), or touch contamination. The risk of, or potential for, critical sites to be contaminated with microorganisms and foreign matter increases with increasing exposed area of the critical sites, the density or concentration of contaminants, and exposure duration to worse than ISO Class 5 (see Table 1) air. Examples include an opened ampul or vial stopper on a 10-mL or larger vial or an injection port on a package of intravenous solution having an area larger than the point of a needle or the tip of a syringe.

The nature of a critical site also affects the risk of contamination. The relatively rough, permeable surface of an elastomeric closure retains microorganisms and other contaminants after swabbing with a sterile 70% IPA pad more readily than does the smoother glass surface of the neck of an ampul. Therefore, the surface disinfection can be expected to be more effective for an ampul.

Protection of critical sites by precluding physical contact and airborne contamination shall be given the highest priority in sterile compounding practice. Airborne contaminants, especially those generated by sterile compounding personnel, are much more likely to reach critical sites than are contaminants that are adhering to the floor or other surfaces below the work level. Furthermore, large and high-density particles that are generated and introduced by compounding manipulations and personnel have the potential to settle on critical sites even when those critical sites are exposed within ISO Class 5 (see Table 1) air.

The most common sources of ISO Class 5 (see Table 1) air quality for exposure of critical sites are horizontal and vertical LAFWs, CAIs, and CACIs. A clean room (see Microbiological Evaluation of Clean Rooms and Other Controlled Environments 1116) is a compounding environment that is supplied with HEPA or HEPA-filtered air that meets ISO Class 7 (see Table 1), the access to which is limited to personnel trained and authorized to perform sterile compounding and facility cleaning. A buffer area is an area that provides at least ISO Class 7 (see Table 1) air quality.

Figure 1 is a conceptual representation of the placement of an ISO Class 5 (see Table 1) PEC in a segregated compounding area used for low-risk level CSPs with 12-hour or less BUD. This plan depicts the most critical operation area located within the PEC in a designated area (see definition of Segregated Compounding Area) separated from activities not essential to the preparation of CSPs. Placement of devices (e.g., computers, printers) and objects (e.g., carts, cabinets) that are not essential to compounding in the segregated area should be restricted or limited, depending on their effect on air quality in the ISO Class 5 (see Table 1) PEC.

Figure 2 is a conceptual representation of the arrangement of a facility for preparation of CSPs categorized as low-, medium-, and high-risk level. The quality of the environmental air increases with movement from the outer boundary to the direct compounding area (DCA). Placement of devices in ante-areas and buffer areas is dictated by their effect on the designated environmental quality of atmospheres and surfaces, which shall be verified by monitoring (see Viable and Nonviable Environmental Sampling (ES) Testing). It is the responsibility of each compounding facility to ensure that each source of ISO Class 5 (see Table 1) environment for exposure of critical sites and sterilization by filtration is properly located, operated, maintained, monitored, and verified.

Placement of devices (e.g., computers, printers) and objects (e.g., carts, cabinets) that are not essential to compounding in buffer areas is dictated by their effect on the required environmental quality of air atmospheres and surfaces, which shall be verified by monitoring (see Viable and Nonviable Environmental Sampling (ES) Testing). It is the responsibility of each compounding facility to ensure that each source of ISO Class 5 (see Table 1) environment for exposure of critical sites and sterilization by filtration is properly located, operated, maintained, monitored, and verified.

Compounding facilities are physically designed and environmentally controlled to minimize airborne contamination from contacting critical sites. These facilities shall also provide a comfortable and well-lighted working environment, which typically includes a temperature of 20 or cooler, to maintain comfortable conditions for compounding personnel to perform flawlessly when attired in the required aseptic compounding garb. PECs typically include, but are not limited to, LAFWs, BSCs, CAIs, and CACIs, which provide an ISO Class 5 (see Table 1) environment for the exposure of critical sites. PECs shall maintain ISO Class 5 (see Table 1) or better conditions for 0.5-µm particles (dynamic operating conditions) while compounding CSPs. Secondary engineering controls such as buffer areas and ante-areas generally serve as a core for the location of the PEC. Buffer areas are designed to maintain at least ISO Class 7 (see Table 1) conditions for 0.5-µm particles under dynamic conditions and ISO Class 8 (see Table 1) conditions for 0.5-µm and larger particles under dynamic conditions for the ante-areas. Airborne contamination control is achieved in the PEC through the use of HEPA filters. The airflow in the PEC shall be unidirectional (laminar flow), and because of the particle collection efficiency of the filter, the “first air” at the face of the filter is, for the purposes of aseptic compounding, free from airborne particulate contamination. HEPA-filtered air shall be supplied in critical areas (ISO Class 5, see Table 1) at a velocity sufficient to sweep particles away from the compounding area and maintain unidirectional airflow during operations. Proper design and control prevents turbulence and stagnant air in the critical area. In situ air pattern analysis via smoke studies shall be conducted at the critical area to demonstrate unidirectional airflow and sweeping action over and away from the product under dynamic conditions.

The principles of HEPA-filtered unidirectional airflow in the work environment shall be understood and practiced in the compounding process in order to achieve the desired environmental conditions. Policies and procedures for maintaining and working within the PEC area shall be written and followed. The policies and procedures will be determined by the scope and risk levels of the aseptic compounding activities utilized during the preparation of the CSPs. The CSP work environment is designed to have the cleanest work surfaces (PEC) located in a buffer area. The buffer area shall maintain at least ISO Class 7 (see Table 1) conditions for 0.5-µm and larger particles under dynamic operating conditions. The room shall be segregated from surrounding, unclassified spaces to reduce the risk of contaminants being blown, dragged, or otherwise introduced into the filtered unidirectional airflow environment, and this segregation shall be continuously monitored. For rooms providing a physical separation through the use of walls, doors, and pass-throughs, a minimum differential positive pressure of 0.02- to 0.05-inch water column is required. For buffer areas not physically separated from the ante-areas, the principle of displacement airflow shall be employed. This concept utilizes a low pressure differential, high airflow principle. Using displacement airflow typically requires an air velocity of 40 ft per minute or more from the buffer area across the line of demarcation into the ante-area.

The displacement concept shall not be used for high-risk compounding.6 The PEC shall be placed within a buffer area in such a manner as to avoid conditions that could adversely affect their operation. For example, strong air currents from opened doors, personnel traffic, or air streams from the HVAC systems can disrupt the unidirectional airflow in open-faced workbenches. The operators may also create disruptions in airflow by their own movements and by the placement of objects onto the work surface. The PEC shall be placed out of the traffic flow and in a manner to avoid disruption from the HVAC system and room cross-drafts. Room air exchanges are typically expressed as ACPHs. Adequate HEPA-filtered airflow supplied to the buffer area and ante-area is required to maintain cleanliness classification during operational activity through the number of ACPHs. Factors that should be considered when determining air-change requirements include number of personnel working in the room and compounding processes that generate particulates, as well as temperature effects. An ISO Class 7 (see Table 1) buffer area and ante-area supplied with HEPA-filtered air shall receive an ACPH of not less than 30. The PEC is a good augmentation to generating air changes in the air supply of an area but cannot be the sole source of HEPA-filtered air. If the area has an ISO Class 5 (see Table 1) recirculating device, a minimum of 15 ACPHs through the area supply HEPA filters is adequate, providing the combined ACPH is not less than 30. More air changes may be required, depending on the number of personnel and processes. HEPA-filtered supply air shall be introduced at the ceiling, and returns should be mounted low on the wall, creating a general top-down dilution of area air with HEPA-filtered make-up air. Ceiling-mounted returns are not recommended. All HEPA filters should be efficiency tested using the most penetrating particle size and should be leak tested at the factory and then leak tested again in situ after installation.7

Activities and tasks carried out within the buffer area shall be limited to only those necessary when working within a controlled environment. Only the furniture, equipment, supplies, and other material required for the compounding activities to be performed shall be brought into the area, and they shall be nonpermeable, nonshedding, cleanable, and resistant to disinfectants. Whenever such items are brought into the area, they shall first be cleaned and disinfected. Whenever possible, equipment and other items used in the buffer area shall not be taken out of the area except for calibration, servicing, or other activities associated with the proper maintenance of the item.

The surfaces of ceilings, walls, floors, fixtures, shelving, counters, and cabinets in the buffer area shall be smooth, impervious, free from cracks and crevices, and nonshedding, thereby promoting cleanability and minimizing spaces in which microorganisms and other contaminants may accumulate. The surfaces shall be resistant to damage by disinfectant agents. Junctures of ceilings to walls shall be coved or caulked to avoid cracks and crevices where dirt can accumulate. If ceilings consist of inlaid panels, the panels shall be impregnated with a polymer to render them impervious and hydrophobic, and they shall be caulked around each perimeter to seal them to the support frame. Walls may be constructed of flexible material (e.g., heavy gauge polymer), panels locked together and sealed, or of epoxy-coated gypsum board. Preferably, floors are overlaid with wide sheet vinyl flooring with heat-welded seams and coving to the sidewall. Dust-collecting overhangs, such as ceiling utility pipes, and ledges, such as windowsills, should be avoided. The exterior lens surface of ceiling lighting fixtures should be smooth, mounted flush, and sealed. Any other penetrations through the ceiling or walls shall be sealed. The buffer area shall not contain sources of water (sinks) or floor drains. Work surfaces shall be constructed of smooth, impervious materials, such as stainless steel or molded plastic, so that they are easily cleaned and disinfected. Carts should be of stainless steel wire, nonporous plastic, or sheet metal construction with good quality, cleanable casters to promote mobility. Storage shelving, counters, and cabinets shall be smooth, impervious, free from cracks and crevices, nonshedding, cleanable, and disinfectable; their number, design, and manner of installation shall promote effective cleaning and disinfection.

PECs (LAFWs, BSCs, CAIs, and CACIs) shall be located within a restricted access ISO Class 7 (see Table 1) buffer area (see Figure 1), with the following CAI/CACI exceptions below:

CAIs and CACIs shall be placed in an ISO Class 7 (see Table 1) buffer area unless they meet all of the following conditions:

It is incumbent on the compounding personnel to obtain documentation from the manufacturer that the CAI/CACI will meet this standard when located in environments where the background particle counts exceed ISO Class 8 (see Table 1) for 0.5-µm and larger particles. When isolators are used for sterile compounding, the recovery time to achieve ISO Class 5 (see Table 1) air quality shall be documented and internal procedures developed to ensure that adequate recovery time is allowed after material transfer before and during compounding operations.

If the PEC is a CAI or CACI that does not meet the requirements above or is a LAFW or BSC that cannot be located within an ISO Class 7 (see Table 1) buffer area, then only low-risk level nonhazardous and radiopharmaceutical CSPs pursuant to a physician order for a specific patient may be prepared, and administration of the CSP shall commence within 12 hours of preparation or as recommended in the manufacturer's package insert, whichever is less.

The ES program should provide information to staff and leadership to demonstrate that the PEC is maintaining an environment within the compounding area that consistently ensures acceptably low viable and nonviable particle levels. The compounding area includes the ISO Class 5 (see Table 1) PEC (LAFWs, BSCs, CAIs, and CACIs), buffer areas, ante-areas, and segregated compounding areas.

Environmental sampling shall occur as part a comprehensive quality management program and shall occur minimally under any of the following conditions:

Food, drinks, and materials exposed in patient care and treatment areas shall not enter ante-areas, buffer areas, or segregated compounding areas where components and ingredients of CSPs are present. When compounding activities require the manipulation of a patient's blood-derived or other biological material (e.g., radiolabeling a patient's or donor's white blood cells), the manipulations shall be clearly separated from routine material-handling procedures and equipment used in CSP preparation activities, and they shall be controlled by specific SOPs in order to avoid any cross-contamination. Packaged compounding supplies and components, such as needles, syringes, tubing sets, and small- and large-volume parenterals, should be uncartoned and wiped down with a disinfectant that does not leave a residue (e.g., sterile 70% IPA), when possible in an ante-area of ISO Class 8 (see Table 1) air quality, before being passed into the buffer areas. Personnel hand hygiene and garbing procedures are also performed in the ante-area, which may contain a sink that enables hands-free use with a closed system of soap dispensing to minimize the risk of extrinsic contamination. There shall be some demarcation designation that separates the ante-area from the buffer area. Adequate provision for performing antiseptic hand cleansing using an alcohol-based surgical hand scrub with persistent activity followed by the donning of sterile gloves should be provided after entry into the buffer area.

Environmental contact is a major source of microbial contamination of CSPs. Consequently, scrupulous attention to cleaning and disinfecting the sterile compounding areas is required to minimize this as a source of CSP contamination.

The cleaning and disinfecting practices and frequencies in this section apply to ISO Class 5 (see Table 1) compounding areas for exposure of critical sites as well as buffer areas, ante-areas, and segregated compounding areas. Compounding personnel are responsible for ensuring that the frequency of cleaning is in accordance with the requirements stated in Table 3 and determining the cleaning and disinfecting products to be used (see Appendix II). Any organizational or institutional policies regarding disinfectant selection should be considered by compounding personnel. All cleaning and disinfecting practices and policies for the compounding of CSPs shall be included in written SOPs and shall be followed by all compounding personnel.

The selection and use of disinfectants in healthcare facilities is guided by several properties, such as microbicidal activity, inactivation by organic matter, residue, and shelf life (see Appendix II). In general, highly toxic disinfectants, such as glutaraldehyde, are not used on housekeeping surfaces (e.g., floors, countertops). Many disinfectants registered by the EPA are one-step disinfectants. This means that the disinfectant has been formulated to be effective in the presence of light to moderate soiling without a pre-cleaning step.

Surfaces in LAFWs, BSCs, CAIs, and CACIs, which are intimate to the exposure of critical sites, require disinfecting more frequently than do housekeeping surfaces such as walls and ceilings. Disinfecting sterile compounding areas shall occur on a regular basis at the intervals noted in Table 3 when spills occur, when the surfaces are visibly soiled, and when microbial contamination is known to have been or is suspected of having been introduced into the compounding areas.

When the surface to be disinfected has heavy soiling, a cleaning step is recommended prior to the application of the disinfectant. Trained compounding personnel are responsible for developing, implementing, and practicing the procedures for cleaning and disinfecting the DCAs written in the SOPs. Cleaning and disinfecting shall occur before compounding is performed. Items shall be removed from all areas to be cleaned, and surfaces shall be cleaned by removing loose material and residue from spills; for example, water-soluble solid residues are removed with sterile water (for injection or irrigation) and low-shedding wipes. This shall be followed by wiping with a residue-free disinfecting agent such as sterile 70% IPA, which is allowed to dry before compounding begins.

Cleaning and disinfecting surfaces in the LAFWs, BSCs, CAIs, and CACIs are the most critical practices before the preparation of CSPs. Consequently, such surfaces shall be cleaned and disinfected frequently, including at the beginning of each work shift, before each batch preparation is started, every 30 minutes during continuous compounding periods of individual CSPs, when there are spills, and when surface contamination is known or suspected from procedural breaches.

Work surfaces in the ISO Class 7 (see Table 1) buffer areas and ISO Class 8 (see Table 1) ante-areas as well as segregated compounding areas shall be cleaned and disinfected at least daily, and dust and debris shall be removed when necessary from storage sites for compounding ingredients and supplies using a method that does not degrade the ISO Class 7 or 8 (see Table 1) air quality (see Disinfectants and Antiseptics 1072).

Floors in the buffer or clean area, ante-area, and segregated compounding area are cleaned by mopping with a cleaning and disinfecting agent once daily at a time when no aseptic operations are in progress. Mopping shall be performed by trained personnel using approved agents and procedures described in the written SOPs. It is incumbent on compounding personnel to ensure that such cleaning is performed properly. In the buffer or clean area, ante-area, and segregated compounding area, walls, ceilings, and shelving shall be cleaned and disinfected monthly. Cleaning and disinfecting agents are to be used with careful consideration of compatibilities, effectiveness, and inappropriate or toxic residues (see Appendix II). Their schedules of use and methods of application shall be in accordance with written SOPs and followed by custodial or compounding personnel.

All cleaning materials, such as wipers, sponges, and mops, shall be nonshedding, preferably composed of synthetic micro fibers, and dedicated to use in the buffer or clean area, ante-area, and segregated compounding areas and shall not be removed from these areas except for disposal. Floor mops may be used in both the buffer or clean area and ante-area, but only in that order. Ideally, all cleaning tools are discarded after one use by collection in suitable plastic bags and removed with minimal agitation. If cleaning materials (e.g., mops) are reused, procedures shall be developed (based on manufacturers' recommendations) that ensure that the effectiveness of the cleaning device is maintained and that repeated use does not add to the bioburden of the area being cleaned.

Supplies and equipment removed from shipping cartons shall be wiped with a suitable disinfecting agent (e.g., sterile 70% IPA) delivered from a spray bottle or other suitable delivery method. After the disinfectant is sprayed or wiped on a surface to be disinfected, the disinfectant shall be allowed to dry, during which time the item shall not be used for compounding purposes.

Wiping with small sterile 70% IPA swabs that are commercially available in individual foil-sealed packages (or a comparable method) is preferred for disinfecting entry points on bags and vials, allowing the IPA to dry before piercing stoppers with sterile needles and breaking necks of ampuls. The surface of the sterile 70% IPA swabs used for disinfecting entry points of sterile packages and devices shall not contact any other object before contacting the surface of the entry point. Sterile 70% IPA wetted gauze pads or other particle-generating material shall not be used to disinfect the sterile entry points of packages and devices.

When sterile supplies are received in sealed pouches designed to keep them sterile until opening, the sterile supplies may be removed from the covering pouches as the supplies are introduced into the ISO Class 5 (see Table 1) PEC (LAFW, BSC, CAI, CACI) without the need to disinfect the individual sterile supply items. No shipping or other external cartons may be taken into the buffer or clean area or segregated compounding area.

The careful cleansing of hands and arms and the correct donning of PPE by compounding personnel constitute the first major step in preventing microbial contamination in CSPs. Personnel shall also be thoroughly competent and highly motivated to perform flawless aseptic manipulations with ingredients, devices, and components of CSPs. Squamous cells are normally shed from the human body at a rate of 106 or more per hour, and those skin particles are laden with microorganisms.10, 11 When individuals are experiencing rashes, sunburn, weeping sores, conjunctivitis, active respiratory infection, as well as when they wear cosmetics, they shed these particles at even higher rates. Particles shed from compounding personnel pose an increased risk of microbial contamination of critical sites of CSPs. Therefore, compounding personnel with such conditions as mentioned above shall be excluded from working in ISO Class 5 (see Table 1) and ISO Class 7 (see Table 1) compounding areas until their conditions are remedied.

Before entering the buffer area or segregated compounding area (see Low-Risk Level CSPs with 12-Hour or Less BUD), compounding personnel shall remove personal outer garments (e.g., bandannas, coats, hats, jackets, scarves, sweaters, vests); all cosmetics, because they shed flakes and particles; and all hand, wrist, and other visible jewelry or piercings (e.g., earrings, lip or eyebrow piercings) that can interfere with the effectiveness of PPE (e.g., fit of gloves and cuffs of sleeves). The wearing of artificial nails or extenders is prohibited while working in the sterile compounding environment. Natural nails shall be kept neat and trimmed.

Personnel shall don the following PPE in an order that proceeds from those activities considered the dirtiest to those considered the cleanest. Garbing activities considered the dirtiest include donning of dedicated shoes or shoe covers, head and facial hair covers (e.g., beard covers in addition to face masks), and face masks/eye shields. Eye shields are optional unless working with irritants such as germicidal disinfecting agents or when preparing hazardous drugs.

After donning dedicated shoes or shoe covers, head and facial hair covers, and face masks, a hand cleansing procedure shall be performed by removing debris from underneath fingernails using a nail cleaner under running warm water followed by vigorous hand washing. Hands and forearms shall be washed to the elbows for at least 30 seconds with soap (either nonantimicrobial or antimicrobial) and water while in the ante-area. The use of antimicrobial scrub brushes is not recommended because they can cause skin irritation and skin damage. Hands and forearms to the elbows will be completely dried using either lint-free disposable towels or an electronic hand dryer. After completion of hand washing, a nonshedding gown with sleeves that fit snugly around the wrists and enclosed at the neck is donned. Gowns designated for buffer area use shall be worn, and preferably they should be disposable. If reusable gowns are worn, they should be laundered appropriately for buffer area use.

Once inside the buffer area or segregated compounding area (see Low-Risk Level CSPs with 12-Hour or Less BUD), and prior to donning sterile powder-free gloves, antiseptic hand cleansing shall be performed using a waterless alcohol-based surgical hand scrub with persistent activity12 following manufacturers' recommendations. Hands are allowed to dry thoroughly before donning sterile gloves.

Sterile gloves shall be the last item donned before compounding begins. Gloves become contaminated when they contact nonsterile surfaces during compounding activities. Disinfection of contaminated gloved hands may be accomplished by wiping or rubbing sterile 70% IPA to all contact surface areas of the gloves and letting the gloved hands dry thoroughly. Only use gloves that have been tested for compatibility with alcohol disinfection by the manufacturer. Routine application of sterile 70% IPA shall occur throughout the compounding process and whenever nonsterile surfaces (e.g. vials, counter tops, chairs, carts) are touched. Gloves on hands shall also be routinely inspected for holes, punctures, or tears and replaced immediately if such are detected. Antiseptic hand cleansing shall be performed as indicated above. Compounding personnel shall be trained and evaluated in the avoidance of touching critical sites.

When compounding personnel exit the compounding area during a work shift, the exterior gown may be removed and retained in the compounding area if not visibly soiled, to be re-donned during that same work shift only. However, shoe covers, hair and facial hair covers, face masks/eye shields, and gloves shall be replaced with new ones before re-entering the compounding area, and proper hand hygiene shall be performed.

During high-risk compounding activities that precede terminal sterilization, such as weighing and mixing of nonsterile ingredients, compounding personnel shall be garbed and gloved the same as when performing compounding in an ISO Class 5 (see Table 1) environment. Properly garbed and gloved compounding personnel who are exposed to air quality that is either known or suspected to be worse than ISO Class 7 (see Table 1) shall re-garb PPE along with washing their hands properly, performing antiseptic hand cleansing with a waterless alcohol-based surgical hand scrub, and donning sterile gloves upon re-entering the ISO Class 7 (see Table 1) buffer area. When CAIs and CACIs are the source of the ISO Class 5 (see Table 1) environment, the garbing and gloving requirements for compounding personnel should be as described above, unless the isolator manufacturer can provide written documentation based on validated environmental testing that any component(s) of PPE or personnel cleansing are not required.

Personnel who prepare CSPs shall be trained conscientiously and skillfully by expert personnel and through multimedia instructional sources and professional publications in the theoretical principles and practical skills of garbing procedures, aseptic work practices, achieving and maintaining ISO Class 5 (see Table 1) environmental conditions, and cleaning and disinfection procedures. This training shall be completed and documented before any compounding personnel begin to prepare CSPs. Compounding personnel shall complete didactic training, pass written competence assessments, undergo skill assessment using observational audit tools, and media-fill testing (see Appendices III–V).

Media-fill testing of aseptic work skills shall be performed initially before beginning to prepare CSPs and at least annually thereafter for low- and medium-risk level compounding and semiannually for high-risk level compounding.

Compounding personnel who fail written tests or observational audits or whose media-fill test vials have one or more units showing visible microbial contamination shall be re-instructed and re-evaluated by expert compounding personnel to ensure correction of all aseptic work practice deficiencies. Compounding personnel shall pass all evaluations prior to resuming compounding of sterile preparations. In addition to didactic evaluation and aseptic media fill, compounding personnel must demonstrate proficiency of proper hand hygiene, garbing, and consistent cleaning procedures.

In the event that cleaning and disinfecting procedures are also performed by other support personnel (e.g., institutional environmental services, housekeeping), thorough training of proper hand hygiene, garbing, and cleaning and disinfection procedures shall be done by a qualified aseptic compounding expert. After completion of training, support personnel shall routinely undergo performance evaluation of proper hand hygiene, garbing, and all applicable cleaning and disinfecting procedures conducted by a qualified aseptic compounding expert.

The value of viable microbial monitoring of gloved fingertips and surfaces of components and the compounding environment are realized when the data are used to identify and correct an unacceptable work practice. Sampling data shall be collected and reviewed on a routine basis as a means of evaluating the overall control of the compounding environment. If an activity consistently shows elevated levels of microbial growth, competent microbiology personnel shall be consulted.

Any cfu count that exceeds its respective action level (see Table 4) should prompt a re-evaluation of the adequacy of personnel work practices, cleaning procedures, operational procedures, and air filtration efficiency within the aseptic compounding location. An investigation into the source of the contamination shall be conducted. Sources could include HVAC systems, damaged HEPA filters, and changes in personnel garbing or working practices. The source of the problem shall be eliminated, the affected area cleaned, and resampling performed.

When gloved fingertip sample results exceed action levels after proper incubation, a review of hand hygiene and garbing procedures as well as glove and surface disinfection procedures and work practices shall be performed and documented. Employee training may be required to correct the source of the problem.

Counts of cfu are to be used as an approximate measure of the environmental microbial bioburden. Action levels are determined on the basis of cfu data gathered at each sampling location and trended over time. The numbers in Table 4 should be used only as guidelines. Regardless of the number of cfu identified in the compounding facility, further corrective actions will be dictated by the identification of microorganisms recovered (at least the genus level) by an appropriate credentialed laboratory of any microbial bioburden captured as a cfu using an impaction air sampler. Highly pathogenic microorganisms (e.g., Gram-negative rods, coagulase positive staphylococcus, molds and yeasts) can be potentially fatal to patients receiving CSPs and shall be immediately remedied, regardless of cfu count, with the assistance of a competent microbiologist, infection control professional, or industrial hygienist.

Compounding personnel ascertain that ingredients for CSPs are of the correct identity and appropriate quality using the following information: vendor labels, labeling, certificates of analysis, direct chemical analysis, and knowledge of compounding facility storage conditions.

It is necessary that equipment, apparatus, and devices used to compound a CSP be consistently capable of operating properly and within acceptable tolerance limits. Written procedures outlining required equipment calibration, annual maintenance, monitoring for proper function, and controlled procedures for use of the equipment and specified time frames for these activities are established and followed. Routine maintenance and frequencies shall be outlined in these SOPs. Results from the equipment calibration, annual maintenance reports, and routine maintenance are kept on file for the lifetime of the equipment. Personnel are prepared through an appropriate combination of specific training and experience to operate or manipulate any piece of equipment, apparatus, or device they may use when preparing CSPs. Training includes gaining the ability to determine whether any item of equipment is operating properly or is malfunctioning.

The accuracy of an ACD can be determined in various ways to ensure that the correct quantities of nutrients, electrolytes, or other nutritional components are delivered to the final infusion container. Initially, the ACD is tested for its volume and weight accuracy. For volume accuracy, a suitable volume of Sterile Water for Injection, USP, which represents a typical additive volume (e.g., 40 mL for small-volume range of 1 to 100 mL, 300 mL for large-volume range of 100 to 1000 mL), is programmed into the ACD and delivered to the appropriate volumetric container. The compounding personnel should then consult Volumetric Apparatus 31 for appropriate parameters to assess the volumetric performance of the ACD. For gravimetric accuracy, the balance used in conjunction with the ACD is tested using various weight sizes that represent the amounts typically used to deliver the various additives. Compounding personnel should consult Weights and Balances 41 for acceptable tolerances of the weights used. In addition, the same volume of Sterile Water for Injection used to assess volumetric accuracy is then weighed on the balance used in conjunction with the ACD. For example, if 40 mL of water was used in the volumetric assessment, its corresponding weight should be about 40 g (assuming the relative density of water is 1.0). In addition, during the use of the ACD, certain additives, such as potassium chloride (corrected for density differences), can also be tested in the same manner as with an in-process test.

Finally, additional tests of accuracy may be employed that determine the content of certain ingredients in the final volume of the parenteral nutrition admixture. Generally, pharmacy departments do not have the capability to routinely perform chemical analyses such as analyses of dextrose or electrolyte concentrations. Consequently, hospital or institutional laboratories may be called upon to perform these quality assurance tests. However, the methods in such laboratories are often designed for biological, not pharmaceutical, systems. Thus, their testing procedures shall be verified to meet the USP requirements stated in the individual monograph for the component being tested. For example, under Dextrose Injection, the following is stated: It contains not less than 95.0% and not more than 105.0% of the labeled amount of C6H12O6·H2O. The hospital or institutional chemistry laboratories must validate their methods to apply to this range and correct for their typical measurement of anhydrous dextrose versus dextrose monohydrate. Similar ranges and issues exist, for example, for injections of calcium gluconate, magnesium sulfate, and potassium chloride. The critical point is the use of USP references and possible laboratory procedural differences.

The intermediate precision of the ACD can be determined on the basis of the day-to-day variations in performance of the accuracy measures. Thus, compounding personnel shall keep a daily record of the above-described accuracy assessments and review the results over time. This review shall occur at least at weekly intervals to avoid potentially clinically significant cumulative errors over time. This is especially true for additives with a narrow therapeutic index, such as potassium chloride.

All CSPs that are intended to be solutions shall be visually examined for the presence of particulate matter and not administered or dispensed when such matter is observed. The prescription orders, written compounding procedure, preparation records, and expended materials used to make CSPs at all contamination risk levels are inspected for accuracy of correct identities and amounts of ingredients, aseptic mixing and sterilization, packaging, labeling, and expected physical appearance before they are administered or dispensed.

Written procedures for double-checking compounding accuracy shall be followed for every CSP during preparation and immediately prior to release. The double-check system should meet state regulations and include label accuracy and accuracy of the addition of all drug products or ingredients used to prepare the finished product and their volumes or quantities. The used additive containers and, for those additives for which the entire container was not expended, the syringes used to measure the additive should be quarantined with the final products until the final product check is completed. Compounding personnel shall visually confirm that ingredients measured in syringes match the written order being compounded. Preferably, a person other than the compounder can verify that correct volumes of correct ingredients were measured to make each CSP. For example, compounding personnel would pull the syringe plunger back to the volume measured.

When practical, the accuracy of measurements is confirmed by weighing a volume of the measured fluid, then calculating that volume by dividing the weight by the accurate value of the density, or specific gravity, of the measured fluid. Correct density or specific gravity values programmed in ACDs, which measure by weight using the quotient of the programmed volume divided by the density or specific gravity, shall be confirmed to be accurate before and after delivering volumes of the liquids assigned to each channel or port. These volume accuracy checks and the following additional safety and accuracy checks in this section shall be included in the SOP manual of the CSP facility.

All high-risk level CSPs that are prepared in groups of more than 25 identical individual single-dose packages (e.g., ampuls, bags, syringes, vials) or in multiple-dose vials (MDVs) for administration to multiple patients or that are exposed longer than 12 hours at 2 to 8 and longer than 6 hours at warmer than 8 before they are sterilized shall meet the sterility test (see Sterility Tests 71) before they are dispensed or administered. The Membrane Filtration method is the method of choice where feasible (e.g., components are compatible with the membrane). A method not described in the USP may be used if verification results demonstrate that the alternative is at least as effective and reliable as the USP Membrane Filtration method or the USP Direct Inoculation of the Culture Medium method where the Membrane Filtration method is not feasible.

When high-risk level CSPs are dispensed before receiving the results of their sterility tests, there shall be a written procedure requiring daily observation of the incubating test specimens and immediate recall of the dispensed CSPs when there is any evidence of microbial growth in the test specimens. In addition, the patient and the physician of the patient to whom a potentially contaminated CSP was administered are notified of the potential risk. Positive sterility test results should prompt a rapid and systematic investigation of aseptic technique, environmental control, and other sterility assurance controls to identify sources of contamination and correct problems in the methods or processes.

All high-risk level CSPs, except those for inhalation and ophthalmic administration, that are prepared in groups of more than 25 identical individual single-dose packages (e.g., ampuls, bags, syringes, vials) or in MDVs for administration to multiple patients or that are exposed longer than 12 hours at 2 to 8 and longer than 6 hours at warmer than 8 before they are sterilized shall be tested to ensure that they do not contain excessive bacterial endotoxins (see Bacterial Endotoxins Test 85 and Pyrogen Test 151). In the absence of a bacterial endotoxins limit in the official monograph or other CSP formula source, the CSP shall not exceed the amount of USP Endotoxin Units (per hour per kilogram of body weight or square meters of body surface area) specified in Bacterial Endotoxins Test 85 referenced above for the appropriate route of administration.

Compounding facilities shall have at least the following written procedures for verifying the correct identity and quality of CSPs before they are dispensed and administered:

BUDs and expiration dates are not the same (see General Notices and Requirements). Expiration dates for the chemical and physical stability of manufactured sterile products are determined from results of rigorous analytical and performance testing, and they are specific for a particular formulation in its container and at stated exposure conditions of illumination and temperature. When CSPs deviate from conditions in the approved labeling of manufactured products contained in CSPs, compounding personnel may consult the manufacturer of particular products for advice on assigning BUDs based on chemical and physical stability parameters. BUDs for CSPs that are prepared strictly in accordance with manufacturers' product labeling shall be those specified in that labeling or from appropriate literature sources or direct testing. BUDs for CSPs that lack justification from either appropriate literature sources or by direct testing evidence shall be assigned as described in Stability Criteria and Beyond-Use Dating under Pharmaceutical Compounding—Nonsterile Preparations 795.

In addition, compounding personnel may refer to applicable publications to obtain relevant stability, compatibility, and degradation information regarding the drug or its congeners. When assigning a beyond-use date, compounding personnel should consult and apply drug-specific and general stability documentation and literature where available, and they should consider the nature of the drug and its degradation mechanism, the container in which it is packaged, the expected storage conditions, and the intended duration of therapy (see Expiration Date and Beyond-Use Date under Labeling in the General Notices and Requirements). Stability information must be carefully interpreted in relation to the actual compounded formulation and conditions for storage and use. Predictions based on other evidence, such as publications, charts, and tables, would result in theoretical BUDs. Theoretically predicted beyond-use dating introduces varying degrees of assumptions and, hence, a likelihood of error or at least inaccuracy. The degree of error or inaccuracy would be dependent on the extent of differences between the CSPs' characteristics (e.g., composition, concentration of ingredients, fill volume, container type and material) and the characteristics of the products from which stability data or information is to be extrapolated. The greater the doubt of the accuracy of theoretically predicted beyond-use dating, the greater the need to determine dating periods experimentally. Theoretically predicted beyond-use dating periods should be carefully considered for CSPs prepared from nonsterile bulk active ingredients having therapeutic activity, especially where these CSPs are expected to be compounded routinely. When CSPs will be distributed to and administered in residential locations other than healthcare facilities, the effect of potentially uncontrolled and unmonitored temperature conditions shall be considered when assigning BUDs. It must be ascertained that CSPs will not be exposed to warm temperatures (see General Notices and Requirements) unless the compounding facility has evidence to justify stability of CSPs during such exposure.

It should be recognized that the truly valid evidence of stability for predicting beyond-use dating can be obtained only through product-specific experimental studies. Semiquantitative procedures such as thin-layer chromatography (TLC) may be acceptable for many CSPs. However, quantitative stability-indicating assays such as high-performance liquid chromatographic (HPLC) assays would be more appropriate for certain CSPs. Examples include CSPs with a narrow therapeutic index, where close monitoring or dose titration is required to ensure therapeutic effectiveness and to avoid toxicity; where a theoretically established beyond-use dating period is supported by only marginal evidence; or where a significant margin of safety cannot be verified for the proposed beyond-use dating period. In short, because beyond-use dating periods established from product-specific data acquired from the appropriate instrumental analyses are clearly more reliable than those predicted theoretically, the former approach is strongly urged to support dating periods exceeding 30 days.

To ensure consistent practices in determining and assigning BUDs, the compounding facility should have written policies and procedures governing the determination of the BUDs for all compounded products. When attempting to predict a theoretical BUD, a compounded or an admixed preparation should be considered as a unique system that has physical and chemical properties and stability characteristics that differ from its components. For example, antioxidant, buffering, or antimicrobial properties of a sterile vial for injection (SVI) might be lost upon its dilution, with the potential of seriously compromising the chemical stability of the SVI's active ingredient or the physical or microbiological stability of the SVI formulation in general. Thus, the properties stabilized in the SVI formulation usually cannot be expected to be carried over to the compounded or admixed preparation. Preparation-specific, experimentally determined stability data evaluation protocols are preferable to published stability information. Compounding personnel should consult general information chapter Pharmaceutical Stability 1150 for the appropriate stability parameters to be considered when initiating or evaluating a preparation-specific stability study.

Compounding personnel who assign BUDs to CSPs when lacking direct chemical assay results must critically interpret and evaluate the most appropriate available information sources to determine a conservative and safe BUD. The SOP manual of the compounding facility and each specific CSP formula record shall describe the general basis used to assign the BUD and storage conditions.

When manufactured MDVs (see Multiple-Dose Container under Preservation, Packaging, Storage, and Labeling in the General Notices and Requirements) of sterile ingredients are used in CSPs, the stoppers of the MDVs are inspected for physical integrity and disinfected by wiping with a sterile 70% IPA swab before each penetration with a sterile withdrawal device. When contaminants or abnormal properties are suspected or observed in MDVs, such MDVs shall be discarded. The BUD after initially entering or opening (e.g., needle puncturing) multiple-dose containers is 28 days (see Antimicrobial Effectiveness Testing 51) unless otherwise specified by the manufacturer.

The sterility storage and stability beyond-use times for attached and activated (where activated is defined as allowing contact of the previously separate diluent and drug contents) container pairs of drug products for intravascular administration (e.g., ADD-Vantage®, Mini Bag Plus®) shall be applied as indicated by the manufacturer. In other words, follow manufacturers' instructions for handling and storing ADD-Vantage®, Mini Bag Plus®, Add A Vial®, Add-Ease® products, and any others.

To ensure that product potency is retained through the manufacturer's labeled expiration date, compounding personnel shall monitor the drug storage areas within the compounding facility. Controlled temperature areas in compounding facilities include controlled room temperature, 20 to 25 with mean kinetic temperature 25; controlled cold temperature, 2 to 8 with mean kinetic temperature 8; cold temperature, 2 to 8; freezing temperature, 25 and 10 (see General Notices and Requirements) if needed to achieve freezing, and the media-specific temperature range for microbial culture media. A controlled temperature area shall be monitored at least once daily and the results documented on a temperature log. Additionally, compounding personnel shall note the storage temperature when placing the product into or removing the product from the storage unit in order to monitor any temperature aberrations. Suitable temperature recording devices may include a calibrated continuous recording device or a National Institute of Standards and Technology (NIST) calibrated thermometer that has adequate accuracy and sensitivity for the intended purpose, and it shall be properly calibrated at suitable intervals. If the compounding facility uses a continuous temperature recording device, compounding personnel shall verify at least once daily that the recording device itself is functioning properly.

The temperature-sensing mechanisms shall be suitably placed in the controlled temperature storage space to reflect accurately its true temperature. In addition, the compounding facility shall adhere to appropriate procedures of all controlled storage spaces to ensure that such spaces are not subject to significantly prolonged temperature fluctuations as may occur, for example, by leaving a refrigerator door open too long.

Inappropriate processes or techniques involved with packaging, handling, and transport can adversely affect quality and package integrity of CSPs. Although compounding personnel routinely perform many of the tasks associated with these functions, some tasks, such as transport, handling, and placement into storage, may be fulfilled by noncompounding personnel who are not under the direct administrative control of the compounding facility. Under these circumstances, appropriate SOPs shall be established by the compounding facility with the involvement of other departments or services whose personnel are responsible for carrying out those CSP-related functions for which the compounding facility has a direct interest. The performance of the noncompounding personnel is monitored for compliance to established policies and procedures.

The critical requirements that are unique to CSPs and that are necessary to ensure CSP quality and packaging integrity shall be addressed in SOPs. For example, techniques should be specified to prevent the depression of syringe plungers or dislodging of syringe tips during handling and transport. Additionally, disconnection of system components (e.g., where CSPs are dispensed with administration sets attached to them) shall be prevented through the BUD of the CSP. Foam padding or inserts are particularly useful where CSPs are transported by pneumatic tube systems. Regardless of the methods used, the compounding facility must evaluate their effectiveness and the reliability of the intended protection. Evaluation should be continuous—for example, through a surveillance system, including a system of problem reporting to the compounding facility.

Inappropriate transport and handling can adversely affect the quality of certain CSPs having unique stability concerns. For example, the physical shaking that might occur during pneumatic tube transport or undue exposure to heat or light must be addressed on a preparation-specific basis. Alternative transport modes or special packaging measures might be needed for the proper assurance of quality of these CSPs. The use of tamper-evident closures and seals on CSP ports can add an additional measure of security to ensure product integrity regardless of the transport method used.

Chemotoxic and other hazardous CSPs require safeguards to maintain the integrity of the CSP and to minimize the exposure potential of these products to the environment and to personnel who may come in contact with them. Transportation by pneumatic tube should be discouraged because of potential breakage and contamination. Special requirements associated with the packaging, transport, and handling of these agents include the prevention of accidental exposures or spills and the training of personnel in the event of an exposure or spill. Examples of special requirements of these agents also include exposure-reducing strategies such as the use of Luer lock syringes and connections, syringe caps, the capping of container ports, sealed plastic bags, impact-resistant containers, and cautionary labeling.

The compounding facility is responsible for ensuring that CSPs in the patient-care setting maintain their quality until administered. The immediate labeling of the CSP container will display prominently and understandably the requirements for proper storage and expiration dating. Delivery and patient-care-setting personnel shall be properly trained to deliver the CSP to the appropriate storage location. Outdated and unused CSPs shall be returned to the compounding facility for disposition.

SOPs must exist to ensure that storage conditions in the patient-care setting are suitable for the CSP-specific storage requirements. Procedures include daily monitoring and documentation of drug storage refrigerators to ensure temperatures between 2 and 8 and the monthly inspection of all drug storage locations by compounding personnel. Inspections shall confirm compliance with appropriate storage conditions, separation of drugs and food, proper use of MDVs, and the avoidance of using single-dose products as MDVs. CSPs, as well as all other drug products, shall be stored in the patient-care area in such a way as to secure them from unauthorized personnel, visitors, and patients.

Procedures essential for generally ensuring quality, especially sterility assurance, when readying a CSP for its subsequent administration include proper hand washing, aseptic technique, site care, and change of administration sets. Additional procedures may also be essential for certain CSPs, devices, or techniques. Examples where such special procedures are needed include in-line filtration, the operation of automated infusion control devices, and the replenishment of CSPs into the reservoirs of implantable or portable infusion pumps. When CSPs are likely to be exposed to warmer than 30 for more than 1 hour during their administration to patients, the maintenance of their sterility and stability should be confirmed from either relevant and reliable sources or direct testing.

The compounding facility shall have the sole authority to determine when unopened, returned CSPs may be redispensed. Returned CSPs may be redispensed only when personnel responsible for sterile compounding can ensure that such CSPs are sterile, pure, and stable (contain labeled strength of ingredients). The following may provide such assurance: the CSPs were maintained under continuous refrigeration and protected from light, if required, and no evidence of tampering or any readying for use outside the compounding facility exists. Assignment of new storage times and BUDs that exceed the original dates for returned CSPs is permitted only when there is supporting evidence from sterility testing and quantitative assay of ingredients. Thus, initial preparation and thaw times should be documented and reliable measures should have been taken to prevent and detect tampering. Compliance with all procedures associated with maintaining product quality is essential. The CSPs shall not be redispensed if there is not adequate assurance that preparation quality and packaging integrity (including the connections of devices, where applicable) were continuously maintained between the time the CSPs left and the time they were returned. Additionally, CSPs shall not be redispensed if redispensing cannot be supported by the originally assigned BUD.

The assurance of CSPs' quality and packaging integrity is highly dependent on the proper adherence of all personnel to the pertinent SOPs. Compounding personnel shall design, implement, and maintain a formal education, training, and competency assessment program that encompasses all the functions and tasks addressed in the foregoing sections and all personnel to whom such functions and tasks are assigned. This program includes the assessment and documentation of procedural breaches, administration mishaps, side effects, allergic reactions, and complications associated with dosage or administration, such as extravasation. This program should be coordinated with the institution's adverse-events and incident reporting programs.

The following sections describe how to maintain sterility and stability of CSPs until they are delivered to patient care locations for administration.