In January of 2024, Pfizer announced a shortage of long acting benzathine penicillin G (BicillinLA) due to increased demand. The CDC recommends treating syphilis patients with doxycycline if penicillin is not available. The exception to this is pregnant women with syphilis, who should receive penicillin G. This prompted some states to announce that remaining benzathine penicillin G was to be reserved for only pregnant women, and all other patients with syphilis to be treated with doxycycline. Pfizer announced this month that benzathine penicillin G would now have more availability but predicts shortages may be expected through 2024.
The challenges in urgent care include availability, cost, need for refrigerated storage, and infrequent use of benzathine penicillin G. There is also a concern with doxycycline that patients may not be compliant with a full course of treatment. It is much easier to ensure treatment when it is provided in a single dose in clinic at the time of diagnosis. Although other medications such as ceftriaxone, doxycycline and azithromycin have been used successfully to treat syphilis, studies have only supported the use of benzathine penicillin G. For this reason, the only recommended treatment per CDC guidelines is benzathine penicillin G.
The CUCM Clinical Response Committee supports the use of benzathine penicillin G for the treatment of primary and secondary syphilis per CDC guidelines. We recommend clinics stock benzathine penicillin G if possible. If this is not feasible, or unavailable, we recommend aligning with your local public health department or other local clinic or hospital to arrange for patients to receive benzathine penicillin G in a timely fashion. Patients should be treated with doxycycline only if no other option for benzathine penicillin G exists.
As of March 2026, the national shortage of Bicillin L-A continues to significantly impact our ability to provide first-line treatment for syphilis. In response to this ongoing shortage, the CDC and FDA have granted temporary authorization for the importation and use of Lentocilin, an internationally manufactured benzathine penicillin G product, until U.S. supply stabilizes.
CUCM supports the CDC’s recommendation to reserve all remaining domestic Bicillin L-A stock exclusively for pregnant patients, for whom no alternative therapy is acceptable. Preserving this limited supply is essential to preventing congenital syphilis.
For non-pregnant patients, doxycycline remains the preferred alternative when Bicillin L-A is unavailable. However, in cases where:
Lentocilin is an appropriate and effective substitute under the current temporary authorization.
Several state health departments have issued guidance supporting the use of Lentocilin during the shortage, reflecting both the urgency of the situation and the safety profile of the imported product.
Accessing Lentocilin: Clinics may obtain Lentocilin through TopRx at https://www.toprx.com. Ordering is straightforward, and most practices report an average cost of approximately $15/dose, with a minimal order of $150 depending on quantity and shipping. Availability has been stable, though demand is increasing, so early ordering is encouraged.
We will continue to monitor federal and state updates and share new guidance as it becomes available. Thank you for your continued commitment to ensuring safe, evidence-based care during this challenging supply disruption.
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