Update on Bicillin L-A® Shortage in Virginia

Dear Colleague,

This letter provides updated information about the ongoing national shortage of Benzathine Penicillin G (Bicillin L-A®) and the availability of alternative medication to treat syphilis.

Ongoing Bicillin L-A® Shortage and Impact to Virginians

The recovery date for the ongoing national shortage of Bicillin L-A® has been extended to the fourth quarter of 2027. Benzathine Penicillin G is the only recommended treatment for pregnant women and babies with congenital syphilis. In response to the ongoing national shortage, VDH is currently prioritizing select groups of patients to receive Bicillin L-A® in local health department clinics to treat or prevent syphilis:

• Women of any age who are pregnant.
• Women of reproductive age (15-44) regardless of pregnancy status.
• Partners of pregnant women with syphilis.
• Patients who cannot take doxycycline or are highly unlikely to comply with an oral treatment regimen, on a case-by-case basis, and as supply allows.

VDH may consider further restricting Bicillin L-A® to only pregnant patients in the future if required, based on forecasted need. Providers should continue to observe the Centers for Disease Control and Prevention (CDC) guidance to treat non-pregnant adults with alternative regimens.

VDH continues to maintain a small program to deliver free injectable syphilis treatment to providers who can administer treatment and who have identified syphilis in a pregnant woman or person allergic to doxycycline.

Alternative Syphilis Treatment Regimens

Doxycycline

Doxycycline can be used to treat non-pregnant adult patients diagnosed with or exposed to syphilis. Based on stage of infection, the recommended course of treatment with doxycycline is:

• 100mg by mouth, twice daily for 14 days for early syphilis (one year of duration or less)
• 100mg by mouth, twice daily for 28 days for late latent or syphilis of unknown duration.

Please remind patients of the importance of taking all medication as prescribed. Reevaluation for appropriate medication and treatment duration for syphilis is necessary to ensure completion of treatment when poor adherence or intolerance is suspected.

Lentocilin

Benzathine benzylpenicillin tetrahydrate (Lentocilin) is a therapeutic equivalent of Bicillin L-A® which is being temporarily imported into the U.S. in response to the shortage. The CDC has shared guidance for the use of Lentocilin which outlines key differences between the two drugs,and procedures for use. Lentocilin is available for purchase through Cost Plus Drugs.

Other intramuscular formulations of penicillin (such as Bicillin C-R) are not acceptable alternatives for the treatment of syphilis.

Regardless of the antibiotic used, follow up clinically and serologically to ensure at least a fourfold decrease in non-treponemal (RPR) titer occurs within 12 months (in early syphilis) and within 24 months (in latent syphilis). Lack of response in the expected timeframe, comorbidities such as HIV, and/or increases in titers after treatment may require evaluation for reinfection, inadequate treatment and/or neurosyphilis. Neurosyphilis can occur at any stage of syphilis. Patients who meet clinical criteria for neurosyphilis, ocular syphilis, or otic syphilis should be treated with aqueous crystalline penicillin G, 18-24 million units per day, administered as 3-4 million units intravenously every four hours, or continuous infusion for 10-14 days.

Additional Recommendations for Syphilis Prevention

• Screen all pregnant women for syphilis at three points during pregnancy: at first prenatal visit, in the early third trimester (28-32 weeks), and at delivery. Additional screening may be necessary if clinical presentation and/or history suggest a concern for reinfection.
• Screen all sexually active people aged 15-44 years residing in cities and counties with elevated rates of syphilis, regardless of reported risk behaviors. In 2024, 85% of the reproductive-age population of Virginia resided in an area with elevated rates of syphilis.
• Consider point-of-care (POC) syphilis testing in settings where immediate results can expedite treatment and reduce congenital syphilis risk. Positive POC results require additional testing and follow-up to confirm the preliminary rapid test result.
• Discuss doxy PEP with patients who it could benefit. A growing body of evidence has demonstrated significant reductions in syphilis in patients taking doxy PEP as prescribed.
• Refer to VDH’s syphilis resource page and our prior healthcare provider letter from June 2025 for more information.

Any questions about syphilis in Virginia can be referred to Oana Vasiliu at [email protected].

Thank you again for your continued partnership in STI prevention.

Sincerely,

Cameron Webb, MD, JD

State Health Commissioner