The limits of sterility assurance

Sterility means the absence of all viable microorganisms including viruses. At present, a sterility assurance level (SAL) of 10(–6) is generally accepted for pharmacopoeial sterilization procedures, i.e., a probability of not more than one viable microorganism in an amount of one million sterilised items of the final product. By extrapolating the reduction rates following extreme artificial initial contamination, a theoretical overall performance of the procedure of at least 12 lg increments (overkill conditions) is demanded to verify an SAL of 10(–6). By comparison, other recommendations for thermal sterilization procedures demand only evidence that the difference between the initial contamination and the number of test organisms at the end of the process amount to more than six orders of magnitude. However, a practical proof of the required level of sterility assurance of 10(–6) is not possible. Moreover, the attainability of this condition is fundamentally dubious, at least in non-thermal procedures. Thus, the question is discussed whether the undifferentiated adherence to the concept of sterility assurance on the basis of a single SAL of 10(–6) corresponds with the safety requirements in terms of patient or user safety, costs and energy efficiency. Therefore, in terms of practical considerations, a concept of tiered SALs is recommended, analogous to the comparable and well-established categorization into “High-level disinfection”, “Intermediate-level disinfection” and “Low-level disinfection”. The determination of such tiered SALs is geared both to the intended application of the sterilized goods, as well as to the characteristics of the products and the corresponding treatment options. In the case of aseptic preparation, filling and production procedures, a mean contamination probability of 10(–3) is assumed. In automated processes, lower contamination rates can be realized. In the case of the production of re-usable medical devices, a reduction of at least 2 lg increments can be achieved through prior cleaning in validated cleaning and disinfecting devices. By chemical disinfection, a further reduction of ≥5 lg increments is achieved. In the case of sterilized surgical instruments, an additional concern is that they lay opened in contaminated air for the duration of the operation, at least in conventionally ventilated operating theaters. Finally, the amount of pathogens necessary to cause an infection must be considered. By logical consideration of all aspects, it seems possible to partially reduce sterility assurance levels without any loss of safety. Proceeding from this, we would like to make the following suggestions for tiered SAL values, adjusted according to the respective sterilization task: SAL 10(–6) for heat-resistant pharmaceutical preparations (parenterals), suggested term: “Pharmaceutical sterilization”, SAL 10(–4) for heat-resistant medical devices, suggested term: “High-level sterilization”, SAL 10(–3) for heat-sensitive re-usable medical devices, under the precondition of a validated cleaning efficacy of >4 lg increments, suggested term: “Low-level sterilization”.