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#398 Don’t Let It Burn: Doxycycline for post-exposure prophylaxis of sexually transmitted infections


CLINICAL QUESTION
QUESTION CLINIQUE
 Does post-exposure prophylaxis with doxycycline reduce the risk of developing bacterial sexually transmitted infections?

BOTTOM LINE
RÉSULTAT FINAL
 Single-dose doxycyline (200mg within 72 hours of condomless sex) reduces the risk of bacterial sexually transmitted infections from 36% with no prophylaxis to 23% at 9-14 months.  Data is mainly limited to men who have sex with men, and a small number of transgender women; all taking HIV pre-exposure prophylaxis or living with HIV.  Rates of chlamydia and syphilis are lowered but not gonorrhea.


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EVIDENCE
DONNÉES PROBANTES
  • Results statistically different unless indicated.
  • One systematic review of all four recent randomized controlled trials (RCTs). 1727 participants, median age 24-43, 73% men who have sex with men, 1% transgender women, 26% cisgender women, all on HIV pre-exposure prophylaxis or living with HIV. 1 Single-dose doxycycline 200mg (within 72 hours of condomless sex) or no doxycycline. After 9-14 months:
    • Any bacterial sexually transmitted infection (STI): 36% versus 23% (doxycycline), number needed to treat (NNT)=8.
    • Chlamydia: 18% versus 7% (doxycycline), NNT=9.
    • Syphilis: 9.8% versus 2.5% (doxycycline), NNT=14.
    • Gonorrhea: Not statistically different.
    • Participants took 4-7 doses/month.
    • Stopping due to adverse effects: 2%-7% across RCTs.
  • Cisgender women subgroup: No outcome statistically different.1
  • Limitations: Only RCT in cisgender women performed in Kenya where 44% of women in the doxycycline group were possibly non-adherent with no evidence of doxycycline exposure in hair samples;1,2 all studies open-label.1,2
 
CONTEXT
CONTEXTE
  • Sexual practices remained similar between groups (examples: Number of partners or number of condomless sex acts).3,4
  • While development of isolates with antimicrobial resistance has been reported, clinical failures due to resistance were not reported in the RCTs of the systematic review above.5
  • Guidelines recommend discussion of doxycycline post-exposure prophylaxis with all men who have sex with men and transgender women with a history of at least one bacterial STI (gonorrhea, chlamydia, and syphilis) in the last 12 months.6

Donald HIckman September 30, 2025

I am wondering if prophylaxis like this would help those with fewer partners and in heterosexual populations

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Author(s)
Auteur(s)
  • Adrienne J Lindblad BSP ACPR PharmD
  • Nwakuru Osigbe MRCGP CCFP
  • Jessica Kirkwood MD CCFP (AM)

1. Sokoll PR, Migliavaca CB, Döring S, et al. Sex Transm Infect. 2025 Jan 29;101:59-67.

2. Stewart J, Oware K, Donnell D, et al. New Engl J Med. 2023 Dec 21;389:2331-40.

3. Molina JM, Bercot B, Assoumou L, et al. Lancet Infect Dis. 2024 Oct;24:1093-104.

4. Molina JM, Charreau I, Chidiac C, et al. Lancet Infect Dis. 2018 Mar;18:308-17.

5. Vanbaelan T, Manoharan-Basil SS, Kenyon C. BMC Infect Dis. 2024 Apr 4;24(1):376.

6. Centres for Disease Control and Prevention. Sexually Transmitted Infections (STIs). Doxy PEP for Bacterial STI Prevention. Available at: https://www.cdc.gov/sti/hcp/doxy-pep/index.html#:~:text=Prescribe%20doxy%20PEP%2C%20as%20appropriate,200%20mg%20every%2024%20hours. Accessed May 13, 2025.

Authors do not have any conflicts of interest to declare.