{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,27]],"date-time":"2026-10-27T18:36:20Z","timestamp":1793126180139,"version":"4.5.0"},"update-to":[{"DOI":"10.1371\/journal.pmed.1005276","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,10,27]],"date-time":"2026-10-27T00:00:00Z","timestamp":1793059200000}}],"reference-count":36,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T00:00:00Z","timestamp":1792540800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000060","name":"National Institute of Allergy and Infectious Diseases","doi-asserted-by":"publisher","award":["T32 AI007433"],"award-info":[{"award-number":["T32 AI007433"]}],"id":[{"id":"10.13039\/100000060","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:title>Summary points<\/jats:title>\n                  <jats:p>\n                    <jats:list list-type=\"bullet\">\n                      <jats:list-item>\n                        <jats:p>The 2026 WHO guidelines recommending doxycycline post-exposure prophylaxis (doxy-PEP) represent the first global antibiotic prophylaxis recommendation for bacterial sexually transmitted infections (STIs), with provisions for antimicrobial resistance (AMR) monitoring.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>Doxy-PEP should be governed as an adaptive intervention subject to periodic, transparent review, but establishing decision rules faces challenges.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>\n                          Doxy-PEP is expected to select for resistance, including in\n                          <jats:italic>Neisseria gonorrhoeae<\/jats:italic>\n                          ,\n                          <jats:italic>Staphylococcus aureus,<\/jats:italic>\n                          and the gut and skin microbiomes; the scope of clinical consequences is incompletely understood.\n                        <\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>As STI prevalence falls, the benefit per dose declines while the AMR externality per dose is expected to grow, shifting the cost-benefit balance in ways that vary across populations and settings.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>Attributing changes in disease prevalence or resistance patterns to doxy-PEP is methodologically difficult, given incompletely understood and complex drivers of pre-existing trends, surveillance limitations, and heterogeneous uptake, raising questions about study designs, data sources, eligibility criteria, and governance mechanisms.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>A full accounting of benefits and harms is broader than reduced bacterial STI incidence and AMR. Benefits include consideration of patient-centered outcomes such as reduced anxiety regarding STI acquisition, avoidance of repeated treatment visits, and fewer STI-related complications. Harms include drug side effects, such as gastrointestinal adverse effects and concerns about use in pregnancy.<\/jats:p>\n                      <\/jats:list-item>\n                    <\/jats:list>\n                  <\/jats:p>","DOI":"10.1371\/journal.pmed.1005276","type":"journal-article","created":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T17:56:10Z","timestamp":1792605370000},"page":"e1005276","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["How do we monitor doxy-PEP impact and when should we consider revisiting guidelines?"],"prefix":"10.1371","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5646-1314","authenticated-orcid":true,"given":"Yonatan H.","family":"Grad","sequence":"first","affiliation":[{"name":"Harvard T.H. Chan School of Public Health","place":["Boston, Massachusetts, United States of America"],"department":["Department of Immunology and Infectious Diseases"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-7199-3382","authenticated-orcid":true,"given":"Rachel","family":"Mittelstaedt","sequence":"additional","affiliation":[{"name":"Harvard T.H. Chan School of Public Health","place":["Boston, Massachusetts, United States of America"],"department":["Department of Immunology and Infectious Diseases"]},{"name":"Massachusetts General Hospital","place":["Boston, Massachusetts, United States of America"],"department":["Division of Infectious Diseases"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-5955-0815","authenticated-orcid":true,"given":"Remco P. H.","family":"Peters","sequence":"additional","affiliation":[{"name":"Department for HIV, Tuberculosis, Hepatitis and Sexually Transmitted Infections","place":["Geneva, Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,10,21]]},"reference":[{"key":"pmed.1005276.ref001","unstructured":"World Health Organization. Global and regional STI estimates. The Global Health Observatory; 2026. Available from: https:\/\/www.who.int\/data\/gho\/data\/themes\/topics\/global-and-regional-sti-estimates"},{"key":"pmed.1005276.ref002","unstructured":"World Health Organization. Sexually transmitted infections (STIs). 2025. [Cited 2026 September 25]. Available from: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/sexually-transmitted-infections-(stis)"},{"issue":"3","key":"pmed.1005276.ref003","doi-asserted-by":"crossref","first-page":"308","DOI":"10.1016\/S1473-3099(17)30725-9","article-title":"Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: an open-label randomised substudy of the ANRS IPERGAY trial","volume":"18","author":"J-M Molina","year":"2018","journal-title":"Lancet Infect Dis"},{"issue":"14","key":"pmed.1005276.ref004","doi-asserted-by":"crossref","first-page":"1296","DOI":"10.1056\/NEJMoa2211934","article-title":"Postexposure doxycycline to prevent bacterial sexually transmitted infections","volume":"388","author":"AF Luetkemeyer","year":"2023","journal-title":"N Engl J Med"},{"issue":"10","key":"pmed.1005276.ref005","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.1016\/S1473-3099(24)00236-6","article-title":"Doxycycline prophylaxis and meningococcal group B vaccine to prevent bacterial sexually transmitted infections in France (ANRS 174 DOXYVAC): a multicentre, open-label, randomised trial with a 2\u2008\u00d7\u20082 factorial design","volume":"24","author":"J-M Molina","year":"2024","journal-title":"Lancet Infect Dis"},{"issue":"10","key":"pmed.1005276.ref006","doi-asserted-by":"crossref","first-page":"756","DOI":"10.1177\/09564624251352053","article-title":"British Association for Sexual Health and HIV (BASHH) UK national guideline for the use of doxycycline post-exposure prophylaxis (DoxyPEP) for the prevention of syphilis, 2025","volume":"36","author":"J Saunders","year":"2025","journal-title":"Int J STD AIDS"},{"key":"pmed.1005276.ref007","unstructured":"European Centre for Disease Prevention and Control. Public health considerations on the use of doxycycline for post-exposure prophylaxis for bacterial sexually transmitted infections in the EU\/EEA. Stockholm: ECDC; 2026."},{"issue":"7","key":"pmed.1005276.ref008","doi-asserted-by":"crossref","first-page":"381","DOI":"10.5694\/mja2.52258","article-title":"Australian consensus statement on doxycycline post-exposure prophylaxis (doxy-PEP) for the prevention of syphilis, chlamydia and gonorrhoea among gay, bisexual and other men who have sex with men","volume":"220","author":"VJ Cornelisse","year":"2024","journal-title":"Med J Aust"},{"issue":"3","key":"pmed.1005276.ref009","first-page":"466","article-title":"Position statement of the German STI Society on the prophylactic use of doxycycline to prevent STIs (Doxy-PEP, Doxy-PrEP)","volume":"22","author":"German STI Society (DSTIG)","year":"2024","journal-title":"J Dtsch Dermatol Ges"},{"issue":"26","key":"pmed.1005276.ref010","doi-asserted-by":"crossref","first-page":"2400707","DOI":"10.2807\/1560-7917.ES.2025.30.26.2400707","article-title":"Emergent informal use of doxycycline post- and pre-exposure prophylaxis among men who have sex with men and transgender and gender diverse people, the Netherlands, 2024","volume":"30","author":"B Teker","year":"2025","journal-title":"Euro Surveill"},{"key":"pmed.1005276.ref011","unstructured":"World Health Organization. Technical information: doxycycline post-exposure prophylaxis for sexually transmitted infections prevention. 2026 [Cited 2023 October 1]. Available from: https:\/\/www.who.int\/teams\/global-hiv-hepatitis-and-stis-programmes\/guidelines\/stis-guidelines\/doxypep"},{"issue":"2","key":"pmed.1005276.ref012","doi-asserted-by":"crossref","first-page":"1","DOI":"10.15585\/mmwr.rr7302a1","article-title":"CDC clinical guidelines on the use of doxycycline postexposure prophylaxis for bacterial sexually transmitted infection prevention, United States, 2024","volume":"73","author":"LH Bachmann","year":"2024","journal-title":"MMWR Recomm Rep"},{"issue":"6","key":"pmed.1005276.ref013","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1007\/s40265-019-01108-x","article-title":"Drug resistance during HIV pre-exposure prophylaxis","volume":"79","author":"KM Gibas","year":"2019","journal-title":"Drugs"},{"issue":"2","key":"pmed.1005276.ref014","doi-asserted-by":"crossref","first-page":"198","DOI":"10.1056\/NEJMc2504010","article-title":"Expansion of tetM-carrying Neisseria gonorrhoeae in the United States, 2018-2024","volume":"393","author":"D Helekal","year":"2025","journal-title":"N Engl J Med"},{"issue":"11","key":"pmed.1005276.ref015","doi-asserted-by":"crossref","first-page":"100926","DOI":"10.1016\/S2666-5247(24)00168-X","article-title":"Effects of doxycycline post-exposure prophylaxis for prevention of sexually transmitted infections on gonorrhoea prevalence and antimicrobial resistance among men who have sex with men in the USA: a modelling study","volume":"5","author":"E Reichert","year":"2024","journal-title":"Lancet Microbe"},{"issue":"8","key":"pmed.1005276.ref016","doi-asserted-by":"crossref","first-page":"819","DOI":"10.1016\/S1473-3099(26)00123-4","article-title":"Durability of doxycycline effectiveness against gonorrhoea after implementation of post-exposure prophylaxis in southern California, USA: a retrospective, test-negative, observational study","volume":"26","author":"M Yechezkel","year":"2026","journal-title":"Lancet Infect Dis"},{"issue":"6","key":"pmed.1005276.ref017","doi-asserted-by":"crossref","first-page":"1188","DOI":"10.1093\/cid\/ciaf089","article-title":"Potential impact of doxycycline post-exposure prophylaxis on tetracycline resistance in Neisseria gonorrhoeae and Colonization With tetracycline-resistant Staphylococcus aureus and group a streptococcus","volume":"80","author":"OO Soge","year":"2025","journal-title":"Clin Infect Dis"},{"issue":"8","key":"pmed.1005276.ref018","doi-asserted-by":"crossref","first-page":"873","DOI":"10.1016\/S1473-3099(25)00085-4","article-title":"Doxycycline to prevent bacterial sexually transmitted infections in the USA: final results from the DoxyPEP multicentre, open-label, randomised controlled trial and open-label extension","volume":"25","author":"AF Luetkemeyer","year":"2025","journal-title":"Lancet Infect Dis"},{"issue":"3","key":"pmed.1005276.ref019","doi-asserted-by":"crossref","first-page":"729","DOI":"10.1093\/infdis\/jiae381","article-title":"In vitro exposure of Treponema pallidum to subbactericidal doxycycline did not induce resistance: implications for doxycycline postexposure prophylaxis","volume":"231","author":"LC Tantalo","year":"2025","journal-title":"J Infect Dis"},{"issue":"5","key":"pmed.1005276.ref020","doi-asserted-by":"crossref","first-page":"1291","DOI":"10.1093\/jac\/dkaf066","article-title":"Exceedingly high levels of tetracycline resistance in Neisseria gonorrhoeae in eight WHO enhanced gonococcal antimicrobial surveillance programme countries in three WHO regions, 2021-2024-doxycycline post-exposure prophylaxis will unlikely impact gonorrhoea burdens","volume":"80","author":"D Schr\u00f6der","year":"2025","journal-title":"J Antimicrob Chemother"},{"key":"pmed.1005276.ref021","doi-asserted-by":"crossref","first-page":"100871","DOI":"10.1016\/j.lanepe.2024.100871","article-title":"High tetracycline resistance percentages in Neisseria gonorrhoeae in Europe: is doxycycline post-exposure prophylaxis unlikely to reduce the incident gonorrhoea cases?","volume":"38","author":"M Unemo","year":"2024","journal-title":"Lancet Reg Health Eur"},{"key":"pmed.1005276.ref022","article-title":"Antimicrobial drug-resistant Neisseria gonorrhoeae (GC) infections in men using doxycycline postexposure prophylaxis. 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