Europe’s top disease agency has set out how countries could use doxycycline after sex to curb bacterial sexually transmitted infections, while it warns about antibiotic resistance and the need for close monitoring. The European Centre for Disease Prevention and Control (ECDC) published public health considerations on doxycycline post?exposure prophylaxis, known as doxy?PEP, and urged national programmes to weigh benefits against risks in their own settings.
The guidance comes as many countries report rising cases of syphilis, gonorrhoea and chlamydia, which place more pressure on sexual health services. The ECDC focuses on population?level impact, not individual prescribing, and flags the need for clear eligibility, robust surveillance and safeguards for antimicrobial stewardship. Health systems now face choices on how to proceed, who to prioritise, and how to measure outcomes without worsening resistance patterns that already challenge treatment.
Doxy-PEP enters Europe’s STI prevention debate
Across Europe, notifications of bacterial STIs have risen in recent years, after a decade of fluctuating trends and a rebound after the early pandemic years. Public health teams have tested new approaches to curb transmission, including more frequent testing, partner notification and tailored outreach. Doxy?PEP has emerged as a potential additional tool for those at highest risk, based on evidence that a single dose of doxycycline after condomless sex can lower the likelihood of some bacterial infections.
The ECDC guidance gives governments and health agencies a framework to consider the option. It does not mandate widespread rollout. Instead, it sets out factors that shape population?level impact, such as local disease patterns, existing resistance to tetracyclines, clinic capacity, data systems, and equity. The document positions doxy?PEP as one part of comprehensive sexual health services, alongside testing, vaccination, contact tracing and access to condoms.
Evidence shows benefits for some STIs, with limits for others
Randomised trials and open?label studies in high?risk groups have reported fewer cases of chlamydia and syphilis among participants who used doxy?PEP. Researchers have observed mixed results for gonorrhoea, in part because many gonorrhoea strains already resist tetracyclines in several countries. That baseline resistance reduces the likely direct effect of doxy?PEP on gonorrhoea transmission and treatment outcomes.
The evidence base remains strongest for specific populations, including gay, bisexual and other men who have sex with men, and some transgender people with recent bacterial STIs or high exposure risk. Researchers still study longer?term outcomes, including effects beyond one year, impacts on the microbiome, and the trajectory of resistance in both STI pathogens and other bacteria that live on the skin and in the gut. The ECDC highlights these uncertainties and calls for ongoing evaluation if programmes adopt doxy?PEP.
Antimicrobial resistance sits at the centre of policy choices
Health authorities face a clear trade?off. Doxy?PEP could reduce the burden of some STIs in groups that face high incidence. At the same time, additional antibiotic use can drive resistance in target pathogens and in bystander bacteria. Many European settings already report high levels of tetracycline resistance in Neisseria gonorrhoeae. Wider doxycycline use could add selective pressure on organisms such as Staphylococcus aureus and commensal gut bacteria. These dynamics matter at a population level, because shifts in resistance complicate treatment for a range of infections.
The ECDC places antimicrobial stewardship at the heart of its considerations. It points to the need for strong laboratory surveillance, standardised resistance testing, and routine data on use, outcomes and adverse events. Health systems would need to track resistance trends not only in STIs but also in sentinel organisms from community and hospital settings. This monitoring would help programmes adjust eligibility, dosing policies and scale.
Targeted implementation, not a blanket rollout
The guidance steers countries towards targeted use in settings with high STI incidence and established sexual health infrastructure. Agencies would need to define clear eligibility and set strict prescribing and supply controls if they choose to proceed. They would also need to align doxy?PEP with existing prevention tools, including HIV pre?exposure prophylaxis services, vaccination against hepatitis A and B, and syphilis screening.
Clear protocols can support consistent decision?making across clinics. These include consent processes, dosing instructions, follow?up testing schedules, and reporting requirements. The ECDC stresses the importance of programme oversight. Health teams would need to audit use and outcomes, review resistance data and adjust policies as evidence evolves.
Health equity and service capacity shape outcomes
Any new intervention can widen gaps if access remains uneven. The ECDC notes that programmes should plan for equitable access, especially for communities that face barriers to care. These include people who do not register with general practitioners, people who live far from clinics, migrants, and those who face stigma. Health services also need to consider language, confidentiality and culturally competent care when they design delivery pathways.
Capacity matters. Many sexual health clinics report heavy workloads and staffing gaps. If countries add doxy?PEP, they would need to resource clinics to meet demand, ensure consistent supply of medicines, and protect time for counselling and testing. Health systems would also need to communicate the goals and limits of doxy?PEP clearly, so people understand that it reduces risk for some infections but does not replace routine screening or vaccination.
Data collection and evaluation underpin any scale-up
The ECDC frames doxy?PEP as a public health intervention that requires evaluation. Programmes would need to collect anonymised data on uptake, demographics, adherence, STIs diagnosed, adverse events and resistance markers. They would also need to use standard definitions and share data with national surveillance teams. This approach supports comparisons across regions and time.
Evaluation should include measures of effectiveness and unintended effects. These include changes in STI testing rates, shifts in sexual health service use, and any signals of resistance in both STI pathogens and commensal organisms. Agencies may also review cost?effectiveness in their local context, since drug prices, clinic costs and STI incidence vary across Europe.
Europe watches international experience, but local context drives decisions
Public health bodies outside Europe have already explored doxy?PEP through trials, pilots and clinical guidance. Those experiences show that clear eligibility criteria, strong surveillance and early attention to resistance help shape safe implementation. They also show that baseline resistance patterns influence outcomes, especially for gonorrhoea.
European countries sit within diverse health systems and regulatory environments. Some may opt for time?limited pilots in defined cities. Others may integrate doxy?PEP into existing programmes for people at highest risk and review impact after a set period. Cross?border collaboration on surveillance, laboratory methods and data standards can support consistent interpretation and faster course corrections.
What this means
The ECDC has set a cautious, evidence?informed path for countries that want to consider doxy?PEP in their STI prevention mix. The guidance encourages targeted use, not a blanket rollout. It places antimicrobial resistance, surveillance and service capacity at the centre of decision?making. If health systems design programmes with strict eligibility, strong monitoring and equitable access, they could reduce chlamydia and syphilis in high?incidence groups while protecting antibiotic effectiveness. The balance will differ by country, given varied resistance patterns, clinic capacity and budgets. The next phase will likely involve controlled pilots, stronger laboratory networks and regular public reporting. That approach can build a clearer picture of population?level benefits and risks, and it can help Europe adjust strategy as new evidence emerges.
When and where
The European Centre for Disease Prevention and Control, headquartered in Stockholm, published its public health considerations on doxycycline post?exposure prophylaxis on 19 January 2026. Source: ECDC news release and accompanying guidance overview.
