Pfizer issued a recall on the medication last summer after finding particulates in some batches. As an injectable penicillin treatment, it can be used for a variety of issues, but it is the only recommended treatment for syphilis for pregnant patients.
Some of those other issues include things like treating strep throat. But with critically low supplies, doses are typically reserved for particular patients, says Dr. Kayla Stover with the University of Mississippi School of Pharmacy, even with syphilis cases.
"If and only if the patient is pregnant and has that particular situation of syphilis and pregnancy, then they are allotted the by so on at my hospital right now," said Stover. "Anybody else gets alternatives."
Those alternatives are typically considered effective, but more involved, like taking multiple pills a day for extended periods instead of getting a handful of Bicillin shots.
"Even on cases where people need multiple doses for syphilis, it's still three doses over three weeks and it's pretty easy from a patient compliance standpoint," said Stover.
Taking those medications, whether through shots or pills, Stover said, is critically important to prevent passing on syphilis to an unborn child and in keeping pregnant patients healthy as well.
"Mom could deliver early, low birth weight," said Stover. "There could be developmental delays, there could complications like blindness in the baby or skeletal deformities and complications could be up to and including death."
Bicillin doses are available through the state health department and at certain hospitals for those patients who providers decide meet the criteria for needing Bicillin, as opposed to alternative medications.
"Any of the providers throughout the state currently can refer their patients to our local health department clinics," said Dr. Tami Brooks, medical director for the Mississippi State Department of Health, adding that those providers have to report those syphilis cases.
"We attack it in our field with getting that patient treated and closing the loop and then our disease intervention specialist in our office of communicable diseases also tracks that case to make sure they get in, that their partners get treated."
Mississippi has, for a number of years, had notably high rates of syphilis, particularly maternal syphilis. Brooks said that since 2023, rates of syphilis in women have gone down generally, as well as cases of congenital syphilis.
But, she said that numbers are still higher than they'd like and other numbers suggest that like the rest of the nation, cases of other types of syphilis may be rising in Mississippi.
"The cases nationwide of syphillis are actually rising, especially for congenital syphilis: in 2024, for example, in Mississippi, there was a tenfold increase in cases of congenital syphilis," said Stover.
Brooks said that's why it's important to prioritize and be strategic about getting Bicillin doses to patients. But with shortages for the last few years, particularly now with the Pfizer recall, doses are hard to get for local clinics. Oxford pediatrician Dr. Tanya Fitts says that can create considerable barriers to care, particularly for communities with already-limited access.
"Moms have already had to take off work for their OB visit," said Fitts. "Sometimes they don't get another day off work to be able to go to the health department for that shot."
There's only one domestic manufacturer of Bicillin L-A, which leaves medical providers with few options when something like a recall happens. Fitts said that compounds other issues with the drug.
"We saw a change in the payment rate many, many years ago, where the cost of the medication increased dramatically one year and that outpaced the payment rates and that disincentivized practitioners from using LA Bicillin for things in their office, like strep," she said. "That kind of disincentivized people to use it, to decrease the demand for the drug, which then decrease the production of the drug, which then is a spiral that leads us to where we are today."
It's a cost issue for both providers and patients.
"Both Bicillin and the alternative agents cost money, of course, but Bicilin usually isn't felt immediately because it's given inpatient or at the doctor's office," said Stover. "You feel it a little bit more acutely as a patient when you have to go to a pharmacy to pick up something and you may have co-pays or shared costs somehow of those prescriptions."
In March, the U.S. Food and Drug Administration approved temporarily importing an Bicillin alternative from Portugal, but says normal levels of supplies likely won't be in stock until December 2027.
