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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 33  |  Issue : 3  |  Page : 274-277

Multidose bevacizumab (Avastin) vial microbial safety: A real-life scenario


1 Department of Ophthalmology, Santhiram Medical College and General Hospital, Nandyal, Kurnool, Andhra Pradesh, India
2 Department of Ophthalmology, Consultant of Santhiram Superspeciality Hospital, Nandyal, Kurnool, Andhra Pradesh, India

Date of Submission29-Nov-2020
Date of Decision09-Feb-2021
Date of Acceptance10-Feb-2021
Date of Web Publication08-Dec-2021

Correspondence Address:
Dr. Sheshadri Vishnu Mahajan
Department of Ophthalmology, Santhiram Medical College and General Hospital, Nandyal, Kurnool, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_189_20

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  Abstract 


Purpose: The purpose of the study is to evaluate the microbiological safety profile of multidoses of bevacizumab (Avastin) from a single-use vial in a real-life scenario. Methods: In a prospective interventional study, a total of 12 sequential vials of bevacizumab (Avastin) were used for this study. After using each vial for multipuncture, multidoses of intravitreal injections for 1 month, leftover bevacizumab in the vial was again stored in the refrigerator at 4°C. All the vials were sent for microbiological evaluation using Gram staining, potassium hydroxide mount, blood agar, MacConkey agar, and brain–heart infusion broth cultures; both at the opening of each vial and after utilization of 12th vial. Patients receiving intravitreal injections from these vials for various ophthalmic indications were followed up at least 3 months postprocedure for clinical evidence of infection. The Microbiology Laboratory is standardized, especially for ophthalmology specimens, and the media, blood agar and MacConkey, agar were prepared in-house, whereas brain–heart infusion broth is commercial media (HiMedia). Results: All the 12 used vials' microbiological evaluation when evaluated at the opening of vials and 13th month of the study period showed no bacterial or fungal elements. None of the patients who received intravitreal injections from these vials developed clinically detectable ocular infection or inflammation. Conclusion: This study suggests that the contents of multiple-dose bevacizumab (Avastin) vials remain sterile over a period of 1 year without any microbial contamination if proper refrigeration and aseptic precautions are maintained. Multipuncture, multidose Avastin vial utilization with due aseptic precautions and storage shows reliable microbiological safety both in vitro and in vivo over 1 year period.

Keywords: Avastin, bevacizumab, multidose, refrigeration, sterility


How to cite this article:
Priya BA, Mahajan SV, Chandra M R. Multidose bevacizumab (Avastin) vial microbial safety: A real-life scenario. Kerala J Ophthalmol 2021;33:274-7

How to cite this URL:
Priya BA, Mahajan SV, Chandra M R. Multidose bevacizumab (Avastin) vial microbial safety: A real-life scenario. Kerala J Ophthalmol [serial online] 2021 [cited 2022 Jan 17];33:274-7. Available from: http://www.kjophthal.com/text.asp?2021/33/3/274/331936




  Introduction Top


Bevacizumab (Avastin) is a recombinant monoclonal antibody approved by the Food and Drug Administration (FDA) for the intravenous treatment of colorectal cancer.[1]

Its off-label intravitreal use has shown promise for the treatment of proliferative diabetic retinopathy and iris neovascularization.[2],[3]

Bevacizumab is available in a vial containing 100 mg in 4 ml solution and one needs only 0.05 ml for intravitreal injection that accounts to 1.25 mg which is commonly used in an ophthalmology practice. It was reported that anti-VEGF activity of bevacizumab which was left in the vial followed by refrigerating may degrade minimally over 6 months.[4] However, its sterility after multipuncture multidosing utilization has not been determined.

The current practice related to storage of bevacizumab vials is to aliquot and store in 1 ml plastic syringes for intravitreal injections whenever needed which is best done by compounding pharmacy.

However, such facility is not available in all ophthalmic setups. Many other alternatives are being used which include either (1) pooling the patients in a given day and usage of single vial of bevacizumab by puncturing multiple times; (2) aliquoting without using the standards of compounding pharmacy; (3) using single vial of bevacizumab until the drug in it gets completely exhausted.

This study is carried out to know the microbial safety of Avastin vials (with multipuncture multidose utility) which were stored in refrigeration and re-used for 1 month each.


  Methods Top


A prospective interventional, single-center study was conducted over a period of 15 months (July 2018 till September 2019). Patients requiring intravitreal Avastin injections for various ocular conditions as diabetic macular edema, macular edema secondary to venous occlusion, and choroidal neovascular membrane were included in this study after obtaining informed consent. Institutional ethics committee approval was taken.

A total of 12 sequential vials of bevacizumab (Avastin) were used for this study. First, vial was opened in July 2018 (1st study month). Each time, the vial was punctured with 27G needle and tuberculin syringe; the rubber cap of the vial was wiped by isopropyl alcohol, allowed to dry, and disinfected with 10% povidone iodine. Prior utilizing each vial for intravitreal injections, bevacizumab drug from Avastin vial was drawn into tuberculin syringe with aseptic precautions and sent immediately to microbiology laboratory for bacterial and fungal cultures, Gram staining, and potassium hydroxide (KOH) mount. All the vials were always returned to the refrigerator and stored at 4°C at procurement, in between the procedures and the period after utility till the 13th month study period. All the intravitreal injections were given in the operation room under aseptic precautions using 30G needle by a single ophthalmic surgeon. All patients receiving injections from these vials were clinically followed up till the 15th study month end for clinical evidence of ocular infection or inflammation.

Sterility analysis

Gram staining, KOH mount, as well as blood agar, MacConkey agar, and brain–heart infusion broth were used to assess microbial growth. The Microbiology Laboratory is standardized for ophthalmology specimens, and the media, blood agar and MacConckey agar, were prepared in-house, whereas brain–heart infusion broth was commercial media (HiMedia).

MacConkey agar is used mainly in identifying lactose fermenting and Gram-negative enteric pathogens and for inhibiting Gram-positive organisms. Blood agar is an enriched medium used to isolate fastidious organisms and detect hemolytic activity. Gram staining is one of the differential stains that are used to characterize bacteria in one of two groups: either Gram-positive or Gram-negative bacteria. KOH preparation was used for the detection of fungal elements in clinical specimen. Brain–heart infusion broth was used for the detection of fungal growth.


  Results Top


Twelve sequential Avastin vials with in the expiry period were included in this study. All vials were sent for Gram staining, KOH mount, and culture at the opening of vial and after last vial was used. Hence, the first vial was evaluated at the opening and after 12 months of utilization while the 12th vial was evaluated at the opening and at the end of 1 month utility. All vials were negative for bacterial and fungal growth at both evaluations.

Microbiological evaluation of all the vials preinjection and the 13th study month showed no growth of organisms [Table 1].
Table 1: Microbiological evaluation of vials and clinical outcome

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  Discussion Top


Bevacizumab (Avastin) is a recombinant monoclonal antibody approved by the FDA for the intravenous treatment of colorectal cancer.[1] Its off-label intravitreal use has shown promise for the treatment of neovascular age-related macular degeneration, diabetic retinopathy, and iris neovascularization.[2],[3]

It is a preservative free antiangiogenic drug which is intended for single use and the manufacturer recommends that each vial should be used within 8 h after initial puncturing of the vial. It is available in a vial containing 100 mg in 4 ml solution and one needs only 0.05 ml for intravitreal injection that accounts to 1.25 mg which is commonly used in an ophthalmology practice. Therefore, the contents of the vial can be used on multiple patients and there is significant cost-saving.

A study suggested that if aseptic precautions are followed, the contents of multiple-dose vials stored at 4°C will remain sterile and the Anti-Vascular endothelial growth factor (anti- VEGF) activity of bevacizumab stored at 4°C will remain stable for up to 6 months.[5]

Drawing multiple doses from the same vial immediately before injection has the potential for contamination. Increasing the number of punctures also increases the risk of contamination. This could be due to the rubber septum increasingly wiped by fingers or a dirty gauze, rubber stopper leakage, poor aseptic technique (e.g., entering the vial without alcohol swabbing), injection of air into the vial before removal of the solution, a contaminated needle or syringe used to draw medication, and inappropriate storage durations and temperatures.[6],[7]

Our study showed that if proper aseptic precautions are taken such as cleaning the rubber cap with isopropyl alcohol and disinfecting with 10% povidone iodine along with maintaining proper storage conditions and negative preinjection cultures, multiuse vial retains sterility over at least a year's time for its extended use. None of the samples in our study showed microbial contamination during inoculation period or while prolonged refrigerator storage.

Chen et al.[5] showed that if proper aseptic precautions are taken while using bevacizumab, the contents of the multidose vial stored at 4°C for 6 months will remain sterile, even with repeated exposure to room temperature during withdrawal.

The authors checked for sterility at 0, 1, 3, and 6 months. In our study, we checked sterility of the contents of multidose vial over a period of 1 year which does not show any microbial growth.

Intravitreal Avastin prepared by compounding pharmacy and injecting in remote areas showed evidence of intraocular infections in various reports.

There was a comment that these events are seemingly artificial[8] and that multiple piercing of vial is unsafe. In this study we demonstrated that multiple piercing of rubber cap and refrigeration at 4°C did not contaminate the vial.

Kamath et al.[9] demonstrated that by maintaining proper storage and usage precautions. Bevacizumab vial can be used for multiple times without any increase in an incidence of endophthalmitis. This study was done over a period of 20 months and the vial was used for 1 month which was discarded later regardless of volume.

However, surgeons should be aware of legal issues regarding the use of preservative-free single-use bevacizumab vial for administrating multiple doses.

This is the first study which showed laboratory proven microbiological safety of multidose and multipuncture Avastin vial in correlation with clinical real-life scenario.

None of the used vials which were stored at variable period from 1-12 months showed microbiological contamination. None of the patients who received injections from such vials showed clinical evidence of infection or inflammation on follow-up which consolidates faith in use of multidose Avastin vial for intravitreal injections.


  Conclusion Top


In this study, the contents of multiple dose bevacizumab (Avastin) vials remain sterile for a period of 1 year.

Multipuncture, multidose Avastin vial utilization with due aseptic precautions and storage shows reliable microbiological safety both in vitro and in vivo over a 1 year period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hurwitz H, Fehrenbacher L, Novotny W, Cartwright T, Hainsworth J, Heim W, et al. Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. N Engl J Med 2004;350:2335-42.  Back to cited text no. 1
    
2.
Avery RL. Regression of retinal and iris neovascularization after intravitreal bevacizumab (Avastin) treatment. Retina 2006;26:352-4.  Back to cited text no. 2
    
3.
Jorge R, Costa RA, Calucci D, Cintra LP, Scott IU. Intravitreal bevacizumab (Avastin) for persistent new vessels in diabetic retinopathy (IBEPE study). Retina 2006;26:1006-13.  Back to cited text no. 3
    
4.
Bakri SJ, Snyder MR, Pulido JS, McCannel CA, Weiss WT, Singh RJ. Six-month stability of bevacizumab (Avastin) binding to vascular endothelial growth factor after withdrawal into a syringe and refrigeration or freezing. Retina 2006;26:519-22.  Back to cited text no. 4
    
5.
Chen YH, Wu PC, Shiea J, Lo LH, Wu YC, Kuo HK. Evaluation of the sterility, stability, and efficacy of bevacizumab stored in multiple-dose vials for 6 months. J Ocul Pharmacol Ther 2009;25:65-9.  Back to cited text no. 5
    
6.
Sheth NK, Post GT, Wisniewski TR, Uttech BV. Multidose vials versus single-dose vials: A study in sterility and cost-effectiveness. J Clin Microbiol 1983;17:377-9.  Back to cited text no. 6
    
7.
Christensen EA, Mordhorst CH, Jepsen OB. Assessment of risk of microbial contamination by use of multidose containers of injectable products. J Hosp Infect 1992;20:301-4.  Back to cited text no. 7
    
8.
Gonzalez S, Rosenfeld PJ, Stewart MW, Brown J, Murphy SP. Avastin doesn't blind people, people blind people. Am J Ophthalmol 2012;153:196-203.  Back to cited text no. 8
    
9.
Khan AR, Kamath S, Sterility of bevacizumab injection vials on multiple dosage use for intravitreal injections. World Journal of Pharmaceutical Research 5:598-604. Research Article ISSN 2277– 7105.  Back to cited text no. 9
    



 
 
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