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

Health Update

TO: Healthcare Providers

Update on Bicillin® L-A (penicillin G benzathine injectable suspension) Shortage: Inventory Review and Clinical Guidance

2/23/2026

Key Messages:

Pfizer recently updated (PDF) the estimated recovery of the Bicillin L-A shortage to the 4th Quarter of 2026.
The next delivery of Bicillin® L-A 1.2 MU and 2.4 MU prefilled syringes is anticipated to be July 2026; the next delivery of the pediatric 600,000 Units prefilled syringes is expected to be December 2026.
Health care providers and entities should continue to prioritize long-acting penicillin-based treatments (Bicillin® L-A & Lentocilin®) for the treatment of pregnant people with syphilis and infants exposed to syphilis in utero.
Extencilline® is no longer available for distribution.
Oral doxycycline is an acceptable alternative treatment for non-pregnant adults with primary, secondary, early/late latent syphilis and syphilis of unknown duration.
This document also summarizes additional alternative medications with limited data for the treatment of syphilis.

Background

In 2023-2024, the U.S. Food & Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) reported a Bicillin® L-A (penicillin G benzathine injectable suspension) shortage. On July 10, 2025, Pfizer issued a voluntary recall for multiple lots of Bicillin® L-A (1.2 and 2.4 MU doses) due to particulates in the prefilled syringes. Most recently on January 21, 2026, Pfizer released an availability update for Bicillin® L-A prefilled syringes and extended the estimated recovery of the Bicillin L-A shortage to the 4th Quarter of 2026. The next delivery of Bicillin® L-A 1.2 MU and 2.4 MU prefilled syringes is estimated to be July 2026; the next delivery of the pediatric 600,000 Units prefilled syringes is estimated to be December 2026.

Extencilline® and Lentocilin® were previously approved by FDA for temporary importation due to prior Bicillin® L-A shortages. Both are safe for use in pregnant patients and should be administered following standard protocols for treatment of syphilis in pregnancy (PDF). As of January 5, 2026, Extencilline® is no longer available for distribution.

CDPH Recommendations and Prioritization Guidance:

Benzathine penicillin G

As a reminder, benzathine penicillin G is the only known effective antimicrobial for treating syphilis in pregnancy and preventing congenital syphilis. If you are experiencing a Bicillin® L-A drug shortage, the California Department of Public Health (CDPH) recommends use of Bicillin® L-A and equivalent products in the following populations:

Pregnant people with syphilis infection (or exposure) as well as for infants exposed to syphilis in utero who may have congenital syphilis; and
Patients with contraindications to doxycycline (e.g., anaphylaxis, hemolytic anemia, Stevens Johnson syndrome).

Doxycycline

For people with syphilis who are not pregnant and do not have medical contraindications to doxycycline, oral doxycycline is an acceptable alternative, including:

Primary, secondary, or early latent syphilis:

Doxycycline 100mg PO twice a day for 14 days

Late latent syphilis or syphilis of unknown duration:

Doxycycline 100mg PO twice a day for 28 days

This guidance does not preclude clinical judgement in situations in which patients may benefit from treatment with long-acting penicillin-based medications (Bicillin® L-A & Lentocilin®). If sufficient supplies of long-acting penicillin-based medications are available, consider offering this treatment to people who may have difficulty completing the full doxycycline regimen.

Health care providers should continue to source benzathine penicillin G through their authorized wholesalers when available. For situations in which product cannot be accessed through wholesale channels, providers should reach out to their local health department or Pfizer. Pfizer has a Medical Request Process for treating healthcare providers or pharmacy directors to request Bicillin L-A® on a per patient basis to prevent or treat congenital syphilis. Completed medical request forms should be emailed to PISupplyContinuity@pfizer.com.

Tetracycline

While tetracycline has been used for years and can be effective to treat syphilis, adherence is likely to be better with doxycycline than tetracycline because tetracycline can cause more gastrointestinal side effects and requires more frequent dosing (tetracycline 500mg orally 4 times/day for 14 days for primary and secondary syphilis).

Limited Data for Other Alternative Treatment for Syphilis:

There is limited data for additional treatment options for syphilis. However, when no other options exist, providers could consider the following treatment regimens with shared clinical decision-making and close follow-up of serologic titers (e.g., RPR or VRDL at 3-month intervals):

Ceftriaxone

Per CDPH and CDC guidelines, although optimal dosing has not been established, ceftriaxone can be considered as an alternative treatment in non-pregnant people with primary/secondary/early latent syphilis or neurosyphilis when no other treatment options are available. Please see CDPH’s prior guidance on the treatment of syphilis using alternative therapies in non-pregnant persons (PDF).

Primary, secondary, or early latent syphilis: Ceftriaxone 1g daily IM or IV for 10 days
Neuro/ocular or otic syphilis: Ceftriaxone 1g daily IM or IV for 14 days or ceftriaxone 2g daily IM or IV for 10 days

Amoxicillin plus probenecid

While CDPH, CDC and World Health Organization (WHO) guidelines for the treatment of syphilis do not include amoxicillin plus probenecid, some international guidelines (PDF) support the following alternative regimen for syphilis:

Primary, secondary, or early latent syphilis: amoxicillin 500mg PO four times a day plus probenecid 500mg PO four times a day for 14 days

Cefixime and Linezolid

Studies are ongoing as to whether other oral antibiotics, such as cefixime or linezolid, may be effective against syphilis. While emerging data is promising for cefixime 400mg twice daily, study sizes are small and efficacy results biased. As such, cefixime remains investigational. Additionally, once daily linezolid (600mg for 5 days) did not meet non-inferiority criteria relative to benzathine penicillin G for early syphilis. Currently, a pilot study is underway to investigate oral linezolid at twice daily dosing and for a 10-day duration.

Resources

Clinicians should refer to CDC and CDPH STI treatment guidelines for alternative syphilis treatment options as well as the following CDC and previous CDPH communications for guidance on Bicillin® L-A prioritization and use of alternative treatment options for non-pregnant people when necessary to preserve Bicillin® L-A supplies:

Review additional information from Pfizer regarding the current Bicillin® L-A supply and how to order additional product (PDF) or return recalled product (PDF).

Contact your local health department if you are experiencing a Bicillin® L-A shortage or having trouble obtaining the medication.

For clinical questions related to the treatment of syphilis during a Bicillin® L-A shortage, please contact your local health department, CDPH Office of Sexually Transmitted Infections and Hepatitis C Virus by phone or email ((510) 620-3400; stdcb@cdph.ca.gov), or the Sexually Transmitted Diseases Clinical Consultation Network run by the California Prevention Training Center at the University of California San Francisco.