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7694 17 Prescription Container Labeling / Apparatus First Supplement to USP 39NF 34

Adequate white space between lines of text (25%30% of the point size)
White space to separate 1S (USP39) sections on the label such as directions for use versus 1S (USP39) pharmacy information
Horizontal text only
Other measures that can also improve readability:
1S (USP39) Minimize the need to turn the container in order to read lines of text
Never truncate or abbreviate critical information
Use 1S (USP39) highlighting, bolding, and other cues to 1S (USP39) preserve readability (e.g., high-contrast print and light
color for highlighting) and 1S (USP39) emphasize patient-centered 1S (USP39) information or information that facilitates ad-
herence (e.g., refill ordering)
Limit the number of colors used for highlighting ( i.e., 1S (USP39) no more than 1S (USP39) two)
Use of separate lines to distinguish when each dose should be taken

Alternative-Access Methods to Address Visual Impairment

Patients with visual impairment who are unable to read printed prescription container labels often report inadvertently tak-
ing the wrong medication or amount, or taking it at the wrong time or under the wrong instructions, compromising their own
safety. Similarly, if a caregiver is visually impaired, the patient they care for is at risk for medication errors. The magnitude of
this problem increases with aging, as the risk of visual impairment and the number of prescribed medications both increase
with age.
Follow standards for patient-centered prescription labels 1S (USP39)
Provide alternative access for visually impaired patients ( alternative-access methods include 1S (USP39) tactile, auditory, or
enhanced visual systems that may employ advanced mechanics of assistive technology) 3
Enhance communication between the pharmacist and visually impaired patients (and their designated representatives)
such that the pharmacist can explain alternative-access options and together they can identify those best suited to the
patients needs
Once an alternative-access method is identified for the individual patient, the pharmacist shall provide the service or di-
rect the patient to a pharmacy that offers that type of alternative access
Ensure that duplicate accessible labels preserve the integrity of the print prescription drug container label and provide the
same sequence of information as the printed label
Follow specific best practices for each respective alternative-access format employed 1S (USP39)

Microbiological Tests

55 BIOLOGICAL INDICATORSRESISTANCE PERFORMANCE TESTS

Change to read:

INTRODUCTION

A biological indicator (BI) is a well-characterized preparation of a specific microorganism with a known resistance to a specif-
ic sterilization process. The correct use of BIs in the development, validation, and control of sterilization processes requires that
their population and resistance be accurately known. The population and resistance can be selected to confirm the adequacy
of individual sterilization process conditions for an article. The recommendations of Sterilization of Compendial Articles 1229
should be followed for effective BI usage. The methods described below can be used to establish population and resistance,
such that the response of the BI to the subject sterilization process is appropriate. Although the BI manufacturers are required
to maintain rigorous control of population and resistance using the number of replicates as specified below, the end users are
not required to use the same number of replicates for verification of those determinations. Conduct all of the tests described in
this chapter under appropriate microbiological laboratory conditions (see Microbiological Best Laboratory Practices 1117).

3 See Working Group Recommendations from Access Board Working Group on Accessible Prescription Drug Container Labels: http://www.access-board.gov/

guidelines-and-standards/health-care/about-prescription-drug-container-labels/working-group-recommendations.

Official from December 1, 2016

Copyright (c) 2017 The United States Pharmacopeial Convention. All rights reserved.
Accessed from 10.6.1.1 by mvpstn3kts on Thu Apr 06 04:52:36 EDT 2017
First Supplement to USP 39NF 34 Microbiological Tests / 55 Biological IndicatorsPerformance 7695

TOTAL VIABLE SPORE COUNT

Sample Collection/Recovery

PAPER/FIBER INDICATORS

For paper/fiber carrier BIs, remove at least four test samples from their individual containers. Disperse the indicator into com-
ponent fibers by placing the test samples in a sterile vessel containing 100 mL of sterilized Purified Water chilled to 28, and
mechanically disrupt to achieve a homogeneous suspension. For self-contained BIs, aseptically remove four BI carriers from
their containers and proceed as directed above.

INDICATORS ON OTHER SUBSTRATES

For all other biological indicators, remove at least four samples from their individual containers. Place the test samples in a
sterile vessel containing 100 mL of sterilized Purified Water chilled to 28, and mechanically disrupt to achieve a homogene-
ous suspension of the spores in the water.

SPORE SUSPENSIONS

For spore suspensions of BIs, prepare an appropriate serial dilution of the original spore suspension in sterilized Purified Water
chilled to 28, in a sterile container, and follow the viable spore count procedures as specified below. The requirements of
the tests are met if the average number of viable spores is within 50%300% of the labeled count of the spore suspension.

Viable Spore Count

Transfer a 10-mL aliquot of the suspension to a sterile tube. For BIs using spores of Geobacillus stearothermophilus, Bacillus
coagulans, and other thermophilic spore formers, heat the tube containing the suspension in a water bath at 95100 for 15
min (heat shock), starting the timing when the temperature reaches 95. For BIs containing nonthermophilic spore formers,
heat the tube containing the suspension in a water bath at 8085 for 10 min, starting the timing when the temperature of
the spore suspension reaches 80. Cool suspensions rapidly in an ice-water bath at 04. Transfer two 1-mL aliquots to suita-
ble tubes, and make appropriate serial dilutions in sterilized Purified Water. Calculate the dilutions to yield 30300 colonies on
each plate in a pair, when treated as described below. Where the BI has a low spore concentration, it may be necessary to
modify the dilution series and to use more plates at each dilution.
Prepare a separate series of plates for each aliquot. Place 1.0 mL of each selected dilution in each of two 15 100-mm Petri
dishes. Within 20 min, add to each plate 20 mL of SoybeanCasein Digest Agar Medium that has been melted and cooled to
approximately 45. Swirl to attain a homogeneous suspension, and allow it to solidify. Incubate the plates in an inverted posi-
tion at 5560 for thermophilic spore formers and at 3035 for nonthermophilic spore formers or at the optimal recovery
temperature specified by the manufacturer. Examine the plates after at least 48 h, recording for each plate the number of colo-
nies. Calculate the average number of spores per test sample from the results, using the appropriate dilution factor. When
evaluating vendor-supplied BIs, the viable spore count shall be between 50% and 300% of the manufacturer's stated value.

D-VALUE DETERMINATION

Apparatus

The test equipment used for the determination of microbial resistance (D-value) is described in substantial detail in ISO
18472, Sterilization of Health Care ProductsBiological and Chemical IndicatorsTest Equipment (1). The details of individual
Biological Indicator Evaluation Resistometers (BIERs) vary with the specifics of their design and the particular sterilization proc-
ess for which they are used. Provided that the performance of the BIER vessel meets the requirements of the ISO standard for
exposure of the BI, design differences are acceptable. For single-phase sterilization processes where an acceptable BIER has not
been defined, the D-value determination can be accomplished by adapting a BIER design intended for a sterilization process
operating in the same phase. There are no current methods available for D-value determination for multiple-phase sterilization
processes.

Procedure

Carry out the tests for D-value at sterilization conditions consistent with those intended for use. Use 20 replicate test sample
BIs in their original individual containers, subjected to at least five exposure conditions for a total of 100 tests. The number of
exposure conditions is chosen to provide a range of observations from NLT one labeled D-value below the expected survival
time through NLT one labeled D-value above the expected kill time. Place each group on a separate suitable sample holder

Official from December 1, 2016

Copyright (c) 2017 The United States Pharmacopeial Convention. All rights reserved.
 Accessed from 10.6.1.1 by mvpstn3kts on Thu Apr 06 04:52:36 EDT 2017
7696 55 Biological IndicatorsPerformance / Microbiological Tests First Supplement to USP 39NF 34

that permits each sample to be exposed to the prescribed sterilizing condition at a specific location in the sterilizing chamber
of the BIER. Check the BIER apparatus for operating parameters using sample holders without test samples. Select a series of
sterilizing times in increments from the shortest time for the samples to be tested. The differences in sterilizing times over the
series are as constant as feasible, and the difference between adjacent times is NMT 75% of the expected D-value. Test proce-
dures for the use of BIER vessels for the evaluation of microbial resistance are defined in a series of ISO standards under the
11138 series (25). The appropriate standard should be followed for the BI. The test methods and carriers used with the BIER
may be adapted to the specifics of the BI. The method and apparatus used for paper carriers may differ from those for other
carriers and will be substantially different from those used for suspensions of BIs.
The D-value exposure conditions for alternative material carriers are the same as the conditions used to determine the D-
value for paper carriers. If a manufacturer's label permits usage of the BI carrier with multiple sterilization methods, then data
on D-value, survival time, and kill time will need to be provided by the manufacturer for each sterilization method.
For BIs that are spore suspensions, conduct D-value determinations for each of the microorganisms that are provided as a
liquid spore crop suspension. The test is conducted using appropriate serial dilutions predicated upon the stated spore filter of
the suspension in Purified Water in a sterile tube. Where the suspension is placed on or in a substrate such as an elastomeric
closure or formulated product, its resistance may differ from that determined in Purified Water. That difference may be signifi-
cant to the usage of the BIs and appropriate measurements made before use in sterilization validation activities.

Recovery

After completion of the sterilizing procedure for BIs and within a noted time (NMT 4 h), aseptically remove and add each BI
to a suitable medium (see media in Sterility Tests 71) to submerge the BI completely in a suitable tube. For self-contained BIs,
the paper strip is immersed in the self-contained medium according to manufacturers' instructions, within a noted time NMT 4
h. For insoluble items inoculated with a spore suspension, aseptically transfer these items individually to a suitable medium
(see media in 71) to submerge the item completely in the medium. When a sealed aqueous filled container has been inocula-
ted, test the units individually, as described within 71.
Incubate each tube at the optimal recovery temperature appropriate for the BI. Observe each inoculated medium-containing
tube at appropriate intervals for a total of 7 days after inoculation. Where growth is observed at any particular observation
time, further incubation of the test sample(s) concerned may be omitted. Note the number of samples showing no evidence
of growth at any time.
Where Clostridium sporogenes or another anaerobic microorganism is used as a BI, methods for preparation, inoculation, and
recovery methods and media must be adapted to accommodate the use of these anaerobic spore formers.

Calculation

The determination of D-values of BIs can be performed using the Limited Spearman-Karber, Survival Curve Method, or
Stumbo-Murphy-Cochran procedures (68). When the BI has been purchased, use the same method as that defined by the BI
manufacturer to subsequently determine D-values. The use of an alternate method can result in differences that are more an
artifact of the method than a variation in the performance of the BI.

Survival Time and Kill Time

Take two groups of BIs, each consisting of 10 test samples, in their original, individual containers. Place the samples of each
group in suitable sample holders that permit each sample to be exposed to the sterilizing conditions at a specific location in
the BIER chamber.
Expose the samples for the required survival time, enter the chamber, and remove the holder(s) containing the 10 test sam-
ples. Repeat the above procedure immediately, or preheat if a substantial interval has elapsed, so as to subject the second
holder(s) containing 10 test samples similarly to the first conditions, but for the required kill time. Recover BIs as described
above. The Survival Time and Kill Time should be provided by the BI manufacturer and verified by the end user.

REFERENCES

1. American National Standards Institute (ANSI)/Association for the Advancement of Medical Instrumentation (AAMI)/Inter-
national Organization for Standardization (ISO) 18472:2006. Sterilization of health care productsbiological and chemi-
cal indicatorstest equipment. 1st ed. Arlington, VA: AAMI.
2. ANSI/AAMI/ISO 11138-1:2006. Sterilization of health care productsbiological indicatorspart 1: general requirements.
2nd ed. Arlington, VA: AAMI.
3. ANSI/AAMI/ISO 11138-2:2006. Sterilization of health care productsbiological indicatorspart 2: biological indicators
for ethylene oxide sterilization processes. 3rd ed. Arlington, VA: AAMI.
4. ANSI/AAMI/ISO 11138-3:2006. Sterilization of health care productsbiological indicatorspart 3: biological indicators
for moist heat sterilization processes. 1st ed. Arlington, VA: AAMI.

Official from December 1, 2016

Copyright (c) 2017 The United States Pharmacopeial Convention. All rights reserved.
Accessed from 10.6.1.1 by mvpstn3kts on Thu Apr 06 04:52:36 EDT 2017
First Supplement to USP 39NF 34 Biological Tests / 87 Biological Reactivity Tests, In Vitro 7697

5. ANSI/AAMI/ISO 11138-4:2006. Sterilization of health care productsbiological indicatorspart 4: biological indicators

for dry heat sterilization processes. 1st ed. Arlington, VA: AAMI.
6. Pflug IJ. Syllabus for an introductory course in the microbiology and engineering of sterilization processes. 4th ed. St. Paul,
MN: Environmental Sterilization Services; 1980.
7. Pflug IJ, Smith GM. The use of biological indicators for monitoring wet-heat sterilization processes. In: Gaughran ERL, Ker-
eluk K, eds. Sterilization of medical products. New Brunswick, NJ: Johnson and Johnson; 1977:193230.
8. Holcomb RG, Pflug IJ. The Spearman-Karber method of analyzing quantal assay microbial destruction data. In: Pflug IJ, ed.
Microbiology and engineering sterilization processes. St. Paul, MN: Environmental Sterilization Services; 1979. 1S (USP39)

Biological Tests and Assays

87 BIOLOGICAL REACTIVITY TESTS, IN VITRO

The following tests are designed to determine the biological reactivity of mammalian cell cultures following contact with the
elastomeric plastics and other polymeric materials with direct or indirect patient contact or of specific extracts prepared from
the materials under test. It is essential that the tests be performed on the specified surface area. When the surface area of the
specimen cannot be determined, use 0.1 g of elastomer or 0.2 g of plastic or other material for every mL of extraction fluid.
Exercise care in the preparation of the materials to prevent contamination with microorganisms and other foreign matter.
Three tests are described (i.e., the Agar Diffusion Test, the Direct Contact Test, and the Elution Test).1 The decision as to which
type of test or the number of tests to be performed to assess the potential biological response of a specific sample or extract
depends upon the material, the final product, and its intended use. Other factors that may also affect the suitability of a sam-
ple for a specific use are the polymeric composition; processing and cleaning procedures; contacting media; inks; adhesives;
absorption, adsorption, and permeability of preservatives; and conditions of storage. Evaluation of such factors should be
made by appropriate additional specific tests before determining that a product made from a specific material is suitable for its
intended use. Materials that fail the in vitro tests are candidates for the in vivo tests described in Biological Reactivity Tests, In
Vivo 88.

Change to read:

TEST CONTROL

Positive Control

Polyurethane film containing zinc diethyldithiocarbamate (ZDEC)2 or zinc dibutyldithiocarbamate (ZDBC) (IRA 1-Nov-2015)

Cell Culture Preparation

Prepare multiple cultures of L-929 (ATCC cell line CCL 1, NCTC clone 929; alternative cell lines obtained from a standard
repository may be used with suitable validation) mammalian fibroblast cells in serum-supplemented minimum essential medi-
um having a seeding density of about 105 cells per mL. Incubate the cultures at 37 1 in a humidified incubator for NLT 24 h
in a 5 1% carbon dioxide atmosphere until a monolayer, with greater than 80% confluence, is obtained. Examine the pre-
pared cultures under a microscope to ensure uniform, near-confluent monolayers. [NOTEThe reproducibility of the in vitro
biological reactivity tests depends upon obtaining uniform cell culture density.]

1 Further details are given in the following publications of the American Society for Testing and Materials, 1916 Race St., Philadelphia, PA 19103: Standard test

method for agar diffusion cell culture screening for cytotoxicity, ASTM Designation F 895-84; Standard practice for direct contact cell culture evaluation of materi-
als for medical devices, ASTM Designation F 813-83.
2
ZDEC and ZDBC polyurethanes are available from the Food and Drug Safety Center, Hatano Research Institute, Ochiai 7295, Hadanoshi, Kanagawa 257, Ja-
pan. (IRA 1-Nov-2015)

Official from December 1, 2016

Copyright (c) 2017 The United States Pharmacopeial Convention. All rights reserved.