Doxycycline to prevent bacterial sexually transmitted infections: a promising intervention

The incidence of bacterial sexually transmitted infections (STIs) has increased over the past decades to unprecedented figures, and has become a worldwide public health problem. While men who have sex with men (MSM) and transgender women (TGW) are particularly affected, the most detrimental consequences concern cisgender women, and in particular pregnant women. Behavioral modifications have had limited effects so far and vaccines are not available yet, leaving an opportunity for antibiotic prophylaxis. The use of doxycycline has been evaluated in clinical trials showing the safety and the efficacy of postexposure prophylaxis with doxycycline (doxyPEP) in strongly reducing the incidence of Chlamydia infections and syphilis in MSM and TGW, and to a lesser extent of gonorrhea. However no benefit was seen in cisgender women, most likely because of adherence issues. There are still outstanding issues regarding the risk of selecting antibiotic resistance, notably in Neisseria gonorrheae, with the concern of the emergence of cephalosporins resistance. Also, the off-target effects on the microbiome and pathogenic bacteria have not been fully investigated yet. The implementation of doxyPEP has been associated with decreases in STI rates, but still faces several challenges in terms of acceptability, access and equity. Guidelines regarding doxyPEP still differ across countries, from case-by-case use to extended recommendations in at-risk individuals, and there is a need for a more homogeneous approach in the prevention of bacterial STIs.