State of California—Health and Human Services Agency
California Department of Public Health

Health Advisory

TO: Healthcare Providers

Extension of Long-Acting Benzathine Penicillin G (Bicillin® L-A) Shortage

3/18/2024

Key Messages

The FDA and Pfizer announced extension of the long-acting benzathine penicillin G (Bicillin® L-A) shortage, with supplies now estimated to not recover until the 4th quarter of 2024.
Healthcare providers and entities should continue to prioritize long-acting penicillin-based treatments (Bicillin® L-A and Extencilline®) for the treatment of pregnant people with syphilis and infants exposed to syphilis in utero.
Oral doxycycline is an appropriate alternative treatment for non-pregnant adults with primary, secondary, early/late latent syphilis and syphilis of unknown duration.

Background

The Centers for Disease Control and Prevention (CDC) and U.S. Food and Drug Administration (FDA) previously announced the long-acting benzathine penicillin G (Bicillin® L-A) shortage and estimated recovery of supplies not before the 2nd quarter of 2024. Unfortunately, the time for expected recovery of supplies has now been extended to the 4th quarter of 2024. This change is reflected on both the FDA drug shortage webpage and Pfizer injectable product availability report (PDF)[1][2]. Bicillin® L-A and Extencilline® (PDF) are the only recommended treatments for all pregnant people with syphilis and certain infants exposed to syphilis in pregnancy. With continued concern about the number of pregnancies and infants affected by syphilis in California, it is of utmost importance that effective treatments be prioritized for these populations.

Recommendations

Given this extension of the Bicillin® L-A shortage and continued uncertainty regarding the availability of long-acting penicillin-based syphilis treatments, CDPH recommends the following:

Prioritize Bicillin® L-A over Extencilline® for infants exposed to syphilis in utero due to the larger volumes required of Extencilline® injections. If no Bicillin® L-A is available, then Extencilline® can be used in infants.
Prioritize Bicillin® L-A and, if necessary, Extencilline® for pregnant people with syphilis infection (or exposure).
Prioritize Bicillin® L-A and Extencilline® for patients with contraindications to doxycycline (e.g., anaphylaxis, hemolytic anemia, Stevens Johnson syndrome).
Conserve Bicillin® L-A and Extencilline® by using alternative drugs for the treatment of primary, secondary, early/late latent syphilis and syphilis of unknown duration in non-pregnant adults as well as for other infectious diseases (e.g., streptococcal pharyngitis) where oral medications or other effective antimicrobials are available.
CDPH has posted a Health Advisory with the acceptable alternative regimens for the treatment of primary, secondary, early/late latent syphilis and syphilis of unknown duration in non-pregnant adults[3]. Alternative regimens for non-pregnant adults include:

Doxycycline 100 mg PO BID for 14 days is an acceptable alternative for those with primary, secondary, or early latent syphilis.
Doxycycline 100 mg PO BID for 28 days is an acceptable alternative for those with late latent syphilis or syphilis of unknown duration.

Resources

If needed, more information regarding the procurement and use of Extencilline® can be found in the recent CDPH Dear Colleague Letter (PDF)[4]. Contact your local health department if you are experiencing difficulty obtaining Bicillin® L-A or Extencilline®.
For clinical questions related to the treatment of syphilis during the Bicillin® L-A shortage, please contact the Sexually Transmitted Diseases (STD) Clinical Consultation Network, your local health department, or CDPH STD Control Branch at (510) 620-3400 by phone or stdcb@cdph.ca.gov by email.