Antimicrobial resistance concerns should not limit doxycycline post-exposure prophylaxis implementation for bacterial STI prevention

Abstract Bacterial sexually transmitted infections (STIs) including syphilis, chlamydia, and gonorrhea continue to rise in key populations despite prevention efforts. Doxycycline post-exposure prophylaxis (doxy-PEP) has demonstrated efficacy in reducing syphilis and chlamydia in men who have sex with men (MSM) and transgender women (TGW), with variable effects on gonorrhea depending on background levels of tetracycline resistance. However, some sexual health organizations recommend limiting widespread implementation due to antimicrobial resistance concerns. Given the demonstrated efficacy of Doxy-PEP among MSM/TGW, implementation efforts should not be hindered by concerns related to antimicrobial resistance. Instead, efforts to reduce tetracycline use in animal feed are warranted, as well as efforts to reduce overuse in other medical conditions. Doxy-PEP implementation should include efforts related to evaluation and monitoring of local antimicrobial resistance including N. gonorrhoeae. This approach upholds the ethical principle of beneficence (providing efficacious care to patients) while addressing public health concerns related to antimicrobial resistance.