CDC Issues New Guidance on Using Doxycycline for PEP
The Centers for Disease Control and Prevention (CDC) recently published proposed guidelines for the use of doxycycline post-exposure prophylaxis (PEP) for preventing bacterial sexually transmitted infections (STIs).1
This move to doxycycline PEP is on the heels of record-high STIs nationwide. Infections increased by 42% between 2011 and 2021. There were more than 2.5 million cases reported in 2021, according to background information the CDC provided STI Quarterly.
Doxycycline PEP showed benefit in reducing infections of chlamydia, gonorrhea, and syphilis. It could be a new approach to addressing STI prevention in at-risk populations. If providers use it equitably, it could help reduce STIs among those who are disproportionately affected.1
“Doxy PEP is moving STI prevention efforts into the 21st Century,” Jonathan Mermin, MD, MPH, director of the CDC’s National Center for HIV, Viral Hepatitis, STD, and TB Prevention, said in a statement. “We need game-changing innovations to turn the STI epidemic around, and this is a major step in the right direction.”
The STI epidemic has disproportionately hit some vulnerable populations, suggesting the need for novel solutions, such as PEP. Plus, doxycycline is well absorbed and tolerated and has a half-life of 12 hours. Most of its adverse effects, including photosensitivity and gastrointestinal symptoms, resolve after the person stops taking the medication.1
“As we near completion of federal doxy PEP guidelines, we’re requesting input on draft guidelines,” Leandro Mena, MD, director of CDC’s Division of STD Prevention, told STI Quarterly. “Considering multiple perspectives now — particularly from providers, members of communities heavily affected by STIs, and prevention partners — will strengthen the quality and use of the first new STI prevention tool in decades. No prevention tool — no matter how powerful — will change the STI epidemic if it doesn’t reach the people who need it most.’
Some people commenting on the proposed guidance raised concerns about antibiotic overuse if doxycycline PEP becomes commonplace.
“While we certainly have a problem with the explosion of STIs over the last one to two years, one hopes due consideration has been given to the widespread use of doxycycline PEP after potential exposure,” Alan J. Taege, MD, wrote. “Doxy is a widely utilized and useful antibiotic covering many different types of organisms. Experience has shown that overuse of any antibiotic leads to the emergence of resistance.”2
The CDC acknowledged the potential risks and designed the guidelines to maximize the effect of doxy PEP while minimizing antibiotic use and focusing on specific at-risk groups.
Many people asked the CDC to promote more safe sex education and provide free condoms to prevent STIs, rather than risk antibiotic resistance by using PEP.
“As someone with a PhD in molecular biology and microbiology and postdoctoral training in biochemistry, I am concerned about the plan to use doxycycline as a prophylactic for people potentially exposed to STDs. I am aware that doxycycline is already being used as a prophylactic for Lyme disease and malaria,” Julie Bernstein, PhD, wrote. “Doxycycline is one of the few well-absorbed and well-tolerated spectrum antibiotics remaining. While STDs have been rising, it is important to consider whether using it without any evidence of infection will accelerate the development of organisms that are resistant to it. If this occurs, it would then severely hamper our ability to easily treat documented STDs.”3
The CDC guidance noted that doxycycline PEP should be implemented only when there also is a comprehensive sexual health approach that includes risk reduction counseling, STI screening and treatment, vaccination, and linkage to HIV pre-exposure prophylaxis, HIV care, or other appropriate services.
Other commenters raised concerns about doxycycline PEP being recommended for certain groups but not others. Some also mentioned potential drug interactions and side effects.
“Doxycycline, being a broad-spectrum antibiotic, has the potential to alter the gut microbiota’s composition and function,” Michael Ravnitzky of Silver Spring, MD, wrote. “I recommend that the guidelines address doxycycline’s potential impact on the gut microbiome and provide guidance on using probiotics as adjunctive therapy.”4
An anonymous commenter asked the CDC to add clarity to the doxycycline products acceptable for use for doxy PEP, noting that doxycycline hyclate ER 200 mg capsule is significantly more expensive and less accessible to most patients than the 100 mg formulation with doxycycline salts.5
- Centers for Disease Control and Prevention. Guidelines for the use of doxycycline post-exposure prophylaxis for bacterial sexually transmitted infection (STI) prevention; request for comment and informational presentation. Fed Reg. Oct. 2, 2023.
- Taege A. Comment from Taege, Alan. Oct. 10, 2023.
- Bernstein J. Comment from Bernstein, Julie. Oct. 10, 2023.
- Ravnitzky M. Comment from Ravnitzky, Michael. Oct. 3, 2023.
- Anonymous. Comment from Anonymous. Oct. 3, 2023.
The Centers for Disease Control and Prevention recently published proposed guidelines for the use of doxycycline post-exposure prophylaxis for preventing bacterial sexually transmitted infections.
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