USP 797 Laboratory Services

USP 797 is designed for health care institutions, pharmacies and other related facilities to insure the sterilization of drugs that are used in compounding sterile preparations. The environmental monitoring and the microbial evaluation of staff’s sterile techniques in compounding sterile preparations (CSPs) is critical to patient care. All locations of Aerobiology are skilled in enumeration and identification of bacteria and fungi in air samples, surface samples, glove samples and can assist in developing a microbial monitoring program for compliance with USP 797.

Download USP 797 Chain of Custody
Download USP 797 Test Codes
Download USP 797 Technical Brief

RODAC / Contact Plate Sampling Protocol

United States Pharmacopeia (USP), Chapter 797, “Pharmaceutical Compounding, Sterile Preparations” specifies the monitoring of microbiological concentrations on surfaces and air for sterile pharmaceutical compounding.

USP 797 is designed for health care institutions, pharmacies and other related facilities to insure the sterilization of drugs that are used in compounding sterile preparations. The environmental monitoring and the microbial evaluation of staff’s sterile techniques in compounding sterile preparations (CSPs) are critical to patient care. This applies to facilities in which CSPs are prepared, stored, and transported. It affects those involved in sterile compounding; physicians, pharmacists, pharmacy technicians and nurses.

Compliance

USP 797 specifies a written plan and schedule for microbiological monitoring procedures in pharmaceutical cleanrooms. Monitoring locations are selected to test the areas most prone to contamination during compounding. Typically, this would include area sampling in the proximity of Class II biocabinets or barrier isolators (ISO Class 5 containment). The plan needs to specify sampling for the controlled environments of the pharmacy, including the interior of biocabinets and barrier isolators, compounding rooms (ISO Class 7 buffer areas), and anterooms (ISO Class 8 support areas) located outside the buffer area. Each sampling site (air, contact plate, swab or glove fingertip plate) needs to have predetermined alert and action levels as part of the written plan. Any sample result exceeding the action level requires immediate corrective action which may include full-scale cleaning, ventilation, or High Efficiency Particulate Air (HEPA) filter assessment and suspension of drug compounding until retesting verifies compliance.

Environmental Monitoring

Recommended Action levels for Microbial Contamination in Air, Surface and Glove Fingertip

ISO Class Air Samples (cfu*/m3) Glove Fingertip (cfu/plate) Surface Samples (cfu/contact plate**)
5 >1 >3 >3
7 >10 Not Required >5
8 >100 Not Required >100
*cfu = colony forming units **Contact plate may vary from 24 to 30cm2

Media for USP 797 Environmental Monitoring

Media Incubation Time of Incubation
Bacteria TSA 30C to 35C 48 to 72 Hours
Fungi MEA 26C to 30C 5 to 7 Days

 

Test Code Analysis TAT
SURFACE, BACTERIAL Counts w/ ID’s 2-3 Days
SURFACE, FUNGAL Counts w/ ID’s 5-6 Days
AIR, BACTERIAL Count w/ID’s 2-3 Days
AIR, FUNGAL Counts w/ ID’s 5-6 Days
GLOVE FINGERTIP SAMPLING (L & R), BACTERIAL Counts 2 Days
SURFACE, BACTERIAL Counts Only 2 Days
SURFACE, FUNGAL Counts Only 5 Days
AIR, BACTERIAL Counts Only 2 Days
AIR, FUNGAL Counts Only 5 Days
Spore Strip Sterility Check 2-3 Days
Media Fill Kit & Analysis – LOW RISK 7-14 Days
Media Fill Kit & Analysis – MEDIUM RISK (Basic) 7-14 Days
Media Fill Kit & Analysis – MEDIUM RISK (Comprehensive) 7-14 Days
Media Fill Kit & Analysis – HIGH RISK (Basic) 7-14 Days
To learn more about testing and our related services please request information using the form here or call us at (877) 648-9150. Thank you!