Alabama Department of Public Health (ADPH)
Alabama Emergency Response Technology (ALERT)
Health Alert Network (HAN)
May 18, 2023

Limited Supply of Bicillin L-A® and Priority Treatment

Message:
The Alabama Department of Public Health (ADPH) continues to monitor penicillin G benzathine injectable suspension products (Bicillin L-A®) since the announcement by the FDA of limited supply due to increased demand. 

Facts: 
Bicillin L-A® is the first-line recommended treatment for syphilis. It is the only recommended treatment option for infected or exposed pregnant patients.

Syphilis is a systemic disease caused by T. pallidum. The disease has been divided into stages based on clinical findings to guide treatment and follow-up. Primary syphilis classically presents as a single painless ulcer or chancre at the site of infection. Secondary syphilis manifestations can include skin rash, mucocutaneous lesions, and lymphadenopathy. Tertiary syphilis can present with cardiac involvement, gummatous lesions, tabes dorsalis, and general paresis. Latent infections or cases lacking clinical manifestations are detected by serologic testing. Latent syphilis acquired within the preceding year is referred to as early latent syphilis; all other cases of latent syphilis are classified as late latent syphilis or latent syphilis of unknown duration.

If left untreated, syphilis can affect the CNS at any stage of the disease, resulting in neurosyphilis; the visual system (ocular syphilis) causing permanent blindness, the auditory system (otosyphilis) leading to permanent deafness, or congenital syphilis. 

ADPH Recommendations:
•    Healthcare providers should continue to follow the CDC 2021 Treatment Guidelines for syphilis.
•    Prioritize the use of Bicillin L-A® to treat pregnant patients and infants with congenital syphilis. For pregnant women infected or exposed to syphilis, penicillin G benzathine (Bicillin L-A®) is the only recommended therapy. 

     Syphilis Treatment During Pregnancy 
     o    Treat at least 30 days before delivery to prevent congenital syphilis: All pregnant women with signs and systems or a positive syphilis test result.
     o    Primary Syphilis, Secondary Syphilis, or Early Non-Primary and Non-Secondary Syphilis: Benzathine penicillin 2.4 million units IM every week for two weeks at 5-7 days interval.
     o    Syphilis Unknown Duration, Late Syphilis, or Previously Treated before Pregnancy: Benzathine penicillin 2.4 million units IM every week for three weeks at 5-7 days interval. 
     o    Patient Partner Referral: To for treatment to prevent reinfection of the pregnant woman. Learn more: https://www.alabamapublichealth.gov/std/syphilis-prevention.html

•    For men and non-pregnant patients with no true penicillin allergy, early syphilis can be treated with Doxycycline 100mg twice daily for two weeks. Late Syphilis or syphilis of unknown duration can be treated with Doxycycline 100mg PO BID for four weeks. 
•    Contact ADPH in situations in which patients diagnosed with syphilis are not being treated because of the inability to procure Bicillin L-A® in the jurisdiction.

Telephone: 334-206-5350 
Email: std.info@adph.state.al.us
ADPH operates free, confidential STD clinics statewide. To find the closest clinic near you, contact your nearest county health department. Visit https://www.alabamapublichealth.gov/about/locations.html.