| Title: Microbiology Laboratory Management | |||||
| Guidance Number: 91 | |||||
| Prepared by: | Date: | Supersedes: | |||
| Checked by: | Date: | Date Issued: | |||
| Approved by: | Date: | Review Date: | |||
Microbiology Laboratory Management
Introduction
This document provides guidance for the management of microbiology laboratories including the following:
- Proper handling of samples;
- Control and maintenance of reagents, reference standards, buffers, microbial
cultures, and microbiological culture media;
- Monitoring and control of the microbiology laboratory environment;
- Calibration and maintenance of laboratory equipment; and
- Documentation and control of microbiological test results.
- An Inventory of Major Equipment in the Microbiology Laboratory should be maintained and include,
at least, the following information:
- Equipment name, manufacturer, and model number;
- Date of installation; and
- Equipment identification (e.g., asset or serial number).
- A Log Book or Validated Computerized Tracking System should be maintained for
the use, cleaning, and maintenance for each major piece of equipment (e.g., sterilizer,
pH meter, balance, spectrophotometer) in the microbiology laboratory.
- Laboratory Equipment Requiring Repair or Calibration should be clearly marked and, when beyond repair,
the equipment should be removed from the laboratory. A description of the malfunction, repair, or calibration
should be documented. If the equipment is temporarily removed from the laboratory for repair or calibration,
a notation should be made of the removal in the equipment log.
- Calibration Checks of Equipment (e.g., Balances, pH Meters, Automatic Pipettes) that are performed
prior to use should be documented. If a balance or other sensitive equipment is moved, the equipment should
be recalibrated prior to use.
- Items to be Incubated should be placed in the incubator in a manner that prevents mix-ups,
spills, and/or cross contamination. All items being incubated should be clearly labelled.
- Critical Process Parameters (e.g., temperature, pressure) for incubators and sterilization/depyrogenation
units should be identified during qualification and should be automatically monitored, recorded, and alarmed.
Alarm conditions should be investigated and documented.
- An Equipment Cleaning and Maintenance Log should be maintained for each incubator and should include,
at least, the following:
- Cleaning and/or disinfection of the incubator;
- Description of maintenance/calibration;
- Date activity performed; and
- Name/initials of person performing the activity.
- Incubator Records for Samples should include, at least, the following:
- Sample identification;
- Date and time in and out of the incubator as required by the test method;
- Number of sample containers;
- Incubation temperature set point; and
- Name/initials of person performing the activity.
- Sterilization and Depyrogenation Processes used in the microbiology laboratory
should be validated for each load pattern.
- Sterilized Equipment should be labeled with the cycle number and expiration date and stored in a
manner that prevents contamination (e.g., in designated storage area). Wrapped, sterilized items
should be inspected prior to use for dryness and to verify the integrity of the wrapping. Wet or torn,
wrapped sterile items should not be used and should be removed from the work area.
- Training for Personnel Working in the Microbiology Laboratory should include, and
not be limited to, the following, as applicable to the job function:
- Departmental Standard Operating Procedures (SOP);
- Analytical, bioanalytical, or microbiological test methods;
- Preparation and storage of microbial cultures, reagents, buffers, reference standards, and
microbiological culture media;
- BI preparation and testing;
- Laboratory mathematics (e.g., calculation of dilution schemes and microbial
titers);
- Aseptic techniques for applicable test procedures;
- Gowning practices for applicable test procedures;
- Cleaning and disinfection of work areas;
- Environmental monitoring procedures; and
- Use of unidirectional airflow units and biosafety cabinets.
- Qualification of Personnel Performing Test Procedures should include demonstration of the
ability to perform the test methods according to approved written procedures. Requalification
in a test method should be required if the analyst has not performed the method during the past
year or a significant change was made to the method since the analyst was last trained in the method.
- Laboratory Materials, such as reagents, buffers, reference standards, microbial cultures, microbiological culture media,
and BIs that are used during microbiological testing should meet the requirements specified by the applicable method
and should be labelled with, at least, the following information:
- Material name;
- Concentration, if applicable;
- Expiration or re-evaluation date;
- Storage conditions, if other than room temperature (RT);
- Date received or prepared;
- Preparer’s name, if applicable; and
- Date approved or qualified.
- In-House Prepared Culture Media should be handled as follows:
- Media should be prepared following the directions specified in the applicable
compendia or, for dehydrated media, use the manufacturer’s directions for
reconstitution;
- Media should be sterilized shortly after preparation (e.g., 1-2 hours) using a
validated sterilization cycle;
- Labelled dehydrated media and cooled, sterile media should be stored at the
recommended temperature;
- Media preparation and sterilization should be documented; and
- Media should be used within its laboratory qualified expiration date.
- Commercially Prepared Culture Media should be handled as follows:
- Media should be stored at the manufacture’s recommended temperature; and
- The laboratory should review the Certificate of Analysis (COA) for each media
lot and retain the COAs per current retention policies.
- Every Batch/Lot of Media should be tested and stored as follows
- Growth promotion test for all media to establish acceptability and the re-evaluation
date;
- Test for pH and sterility after sterilization for in-house prepared media;
- Media should be re-evaluated by growth promotion testing within three months of
use if used for sterility testing and stored in sealed containers or within two weeks
of use for unsealed containers;
- Prepared media should be stored for not more than one year if sealed and should not
be stored beyond the manufacturer’s recommended storage time if unsealed. Prepared
media should be used within the expiry date;
- Dehydrated media should be stored and used according to the manufacturer’s
recommendations; and
- Prepared media that have been qualified by passing a growth promotion test and
unqualified media that have not completed the growth promotion test should be clearly
labelled and stored separately to prevent mix-ups.
- The Selection and Use of Neutralizers or Inhibitors (e.g., Polysorbate 80, Tween,
Lecithin) that are incorporated into the microbiological culture media, if required, should be
supported with validation studies.
- Microbiology Laboratory Reagents, Buffers, and Reference Standards should be
prepared as follows:
- Starting materials should be stored at the recommended temperature and used within the
expiration date or re-evaluation date;
- Each container of prepared material should be labelled and the preparation date
indicated on the label;
- Containers should be stored at the recommended temperature; and
- Preparation steps should be documented.
- The Microbial Population of BIs should be verified and the D-value and z-value should be known.
Testing for custom BIs should include microbial population, D-value, z-value, survival time, and Kill
Time under the conditions in which they will be used.
- Maintenance of Microbiological Control Cultures should be specified and documented and include,
and not be limited to:
- Seed lot cultures should not be more than five passages removed from the original
culture strain;
- For frozen seed lot cultures, each cycle of freezing, thawing, and revival in fresh
medium is considered to be one passage; and
- Culture strains should be obtained, when feasible, from a recognized reference
source, such as ATCC and NCTC.
- Work Performed in Bio safety Cabinets and Unidirectional Airflow Units should be
conducted as follows:
- Ensure that air intake on the unit is not blocked;
- Verify that pressure differential gauge readings are within specified ranges;
- Turn off any ultraviolet (UV) lamps prior to starting work;
- Disinfect the work surface before and after use;
- Gown according to the requirements for the test method;
- Allow, at least, a 15 minute air purge before use, when the unit is restarted;
- Follow the manufacturer’s recommendations for placement of items on the work
surface;
- Avoid mixing clean items with dirty items;
- Wipe up spills immediately using a disinfectant; and
- Seal waste materials in bags prior to disposal and eventual destruction.
- Automated Microbial Identification Systems should be validated using a recognized
reference source (e.g., ATCC, NCTC). For Microbial Identification Systems using cards
or strips, the performance of each shipment of cards/strips should be evaluated using a
set of known organisms. In systems requiring a complex sample preparation, a set of
known standards should be included with each test performed to evaluate the system’s
performance.
- Automated Quantitation Systems should be validated using preparations having known
quantities of microorganisms. The results from the automated method should be compared
to the results from the standard plate count or Most Probable Number (MPN) method and
should be within a pre-established acceptance criteria range.
- Environmental Monitoring of the Sterility Test Suite should include, and not be
limited to, the following:
- Surface and air monitoring of STIS units, unidirectional airflow units, and
Bio safety cabinets;
- Air monitoring of gowning and clean room facilities, including monitoring of
pressure differential; and
- Gown and glove monitoring using contact plates and touch plates of personnel
performing sterility testing.
- Sample Handling, Testing, and Preparation of Testing Materials should be documented using a
controlled documentation system.
- Approval of Contract Microbiological Testing Laboratories by the Site Quality Team should
include consideration of, and not limited to, the following:
- Historical performance of the contract laboratory;
- Results of audit, if performed; and
- Use of the contract laboratory for routine or special testing (e.g., one time use).
- Contract Microbiological Testing Laboratories when used for routine testing should
include provisions for, and not limited to, the following:
- Sample controls (e.g., date shipped, date received, conditions of shipment);
- Sample retention requirements;
- Investigation and reporting of OOS and questionable results;
- Documentation and reporting procedures; and
- Periodic audits.