1. Situational Update: Bicillin L-A supply for syphilis treatment and exposure

   The nationwide supply of penicillin G benzathine (Bicillin L-A®) is improving.

   • On June 10, 2024, Pfizer shared an update on their 2.4 million Units/4 milliliter Bicillin L-A® supply, noting that they currently have available supply. If there is sufficient supply of Bicillin L-A ® at your healthcare facility, please use Bicillin L-A® as the first line treatment for syphilis of all stages, and for patients who have been exposed to syphilis, per CDC's standard guidance.
      
   • If you are experiencing Bicillin L-A® supply issues, please contact the nursing line at SF City Clinic at (628) 217-6695 and contact Pfizer Hospital US directly at the number or email below:
     Pfizer Hospital US:
     Phone: 844-646-4398
     Hours: M-F 7am-5pm CST
     Email: PISupplyContinuity@Pfizer.com (For assistance with orders/supply information)
      
   • Note Bicillin® L-A supply is improving, but it will not be fully available until later this year, per Pfizer's Availability Report.
      

2. Reports of rare, difficult to treat dermatophyte infections in the United States

   On June 19^th, the California Department of Public Health released a Health Advisory about reports of rare, difficult to treat dermatophyte infections associated with sexual contact in the United States and Europe. The advisory includes important information about the clinical presentation, diagnosis, and management of these infections.

   Dermatophytes, including Trichophyton species, can cause fungal infections of the skin, also known as “tinea” or “ringworm.” Ringworm is common and typically responds to topical anti-fungal treatment. Worldwide, there have been increasing reports of tinea infections that are resistant to topical or oral anti-fungal medications. Currently, there are two tinea species of particular concern, due to cases identified in the United States:

   1. Trichophyton mentagrophytes genotype VII (TMVII) is a rare dermatophyte that has been reported in France, primarily among men who have sex with men (MSM), that can cause highly inflammatory, painful, and persistent lesions, often affecting the anogenital or perioral areas. It may not respond to commonly used topical anti-fungal medications but can be treated using oral anti-fungal medications, including terbinafine. TMVII is reported to be spreading locally in Europe and other global regions. The first known case of TMVII in the United States was reported in June 2024 and occurred in an HIV-negative man in New York City who had sex with men and had recent travel to Europe and California. There have been no confirmed cases of TMVII in San Francisco.
       
   2. Trichophyton indotineae is an emerging, terbinafine-resistant dermatophyte that has been causing outbreaks of extensive and difficult to treat tinea in southern Asia for several years. Multiple cases of Trichophyton indotineae have been identified in New York City. A case of sexually transmitted Trichophyton indotineae was reported in April 2024 in Pennsylvania in a woman who developed symptoms in winter of 2022 after travel to South Asia where she had vaginal intercourse with a male partner with an anogenital rash.

Actions Requested of SF Providers:

• Empirically treat patients with tinea that is non-responsive to topical therapies with oral terbinafine.
• Obtain a fungal culture in patients with tinea infections that do not respond to topical anti-fungal or oral anti-fungal medications. If Trichophyton species is identified by culture, consider contacting one of the following laboratories for genomic sequencing to distinguish between species:
   
  • Wadsworth Mycology Laboratory of the New York State Department of Health (Albany, NY, USA)
  • Fungus Testing Laboratory of the University of Texas Health (San Antonio, TX, USA)  
  • Center for Medical Mycology of the University Hospitals Cleveland Medical Center (Cleveland, OH, USA)
     
• Report cases of resistant tinea to SFDPH, particularly if sexual transmission is suspected and the rash affects the anogenital or perioral region by faxing a CMR (write “resistant tinea” as disease being reported).

Program Contact Information
SFDPH Communicable Disease Section
Tel: 415-554-2860
Fax: 415-554-2848
Email: cdcontrol@sfdph.org

To view or sign up for SFDPH Health Alerts, Advisories, and Updates visit:
sf.gov/healthalerts