San Diego County rationing penicillin as shortage persists, threatening babies at risk of syphilis

Rationing is well underway in San Diego County for a long-lasting form of penicillin used to prevent babies from being born with syphilis.

Pharmaceutical giant Pfizer warned doctors worldwide this month to expect shortages of Bicillin L-A, the only product approved to treat syphilis during pregnancy and prevent serious consequences for newborns from birth defects to stillbirth.

In its June 12 letter, Pfizer attributes the shortage to “a complex combination of factors including significant increases in demand due to an increase in syphilis infection rates as well as competitive shortages.”

San Diego County’s public health department has been following the situation for months, issuing a notice to local doctors on April 25 that the drug could be in short supply, but that a quick resolution was expected. A second update sent June 15 notes that the shortage will be protracted.

“It looks like it will be some time in the second quarter of 2024 before we can expect this to resolve itself,” said Dr. Winston Tilghman, the county’s STD controller.

County recommendations call for Bicillin L-A supplies to be prioritized for pregnant women and for those who are allergic to other forms of penicillin. So far, the county heath department has not learned of any instance where a pregnant woman with syphilis has been unable to get the drug which, if given quickly enough, can prevent the bacteria that cause the disease from colonizing a child still in the womb.

“If we were using Bicillin like we normally use it without the sorts of restrictions that we’ve been recommending, we would probably be out by now,” Tilghman said. “With the prioritization of Bicillin L-A for certain clinical situations, we are stretching it quite well; we’re going through just a couple of doses per week on average here at the county.

“If everyone follows those guidelines that we’ve released, I think we can get through much of this without any major issues.”

Another antibiotic called doxycycline is the recommended replacement for adults. While penicillin is the standard first-line treatment for syphilis, Tilghman said there is plenty of evidence that doxycycline is very effective, though it’s generally taken in oral form — two pills daily.

San Diego County, following a multi-year nationwide trend, is experiencing a surge in the number of reported syphilis cases. According to county records, there were 33.3 “early” syphilis cases per 100,000 residents in 2022 compared to 17 per 100,000 in 2012.

A consequence of that rise has been the increased number of cases among newborns. There were 36 in 2022 compared to just four in 2012.

Syphilis is a chronic bacterial disease that spreads through sexual contact with round firm sores appearing in areas associated with such activity. Generally the sores are painless, but a secondary phase of infection causes fever, swollen lymph nodes, skin rash and wart-like genital lesions, according to the U.S. Centers for Disease Control and Prevention. Infants often have no symptoms at birth but may have nasal “snuffles,” skin rash and a range of other signs.

Long-acting bicillin is a type of penicillin given by injection, usually in the posterior. Tilghman said it is particularly effective at eliminating syphilis.

“It forms sort of a depot in the muscle, and it slowly releases antibiotic for several days,” he said. “It provides the concentration of antibiotic that you need over time to eradicate the bacteria that causes syphilis.

“Because it’s a slow-growing organism, you really need those concentrations to be there for a prolonged period of time to make sure you get all of it.”

Bicillin L-A is also often used to treat strep throat, the irritating condition caused by streptococcus bacteria.

While he said that the county’s sexually transmitted disease clinics have been rationing Bicillin L-A for months, Tilghman said he has no visibility into the prescribing practices of other medical providers across the region.

Dimitrios Alexiou, chief executive officer of the Hospital Association of San Diego and Imperial Counties, said in an email that he had not heard of any instances among the members of his organization where the drug was not available during a pregnancy.

“Locally, we are following the (county recommendation) and conserving per the guidance,” Alexiou said. “Additionally, systems are purchasing whatever they can get access to in order to maintain supplies.”