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This practice also occurs in the United States even though the United States regulates the acquisition of antibiotics, which will be limited by prescription only. As a result, most community assessments of antibiotic reservoirs are based on assessments by prescribing clinician behavior. Although more than half of the identified sites provided online consultation for prescribing, the lack of interaction between the patient and the doctor did not lead to any opportunity for patient education. Other providers are trying to upset this law by providing online diagnoses and prescriptions based on medical records without a physical examination and without a long relationship between the patient and the doctor, a practice that is not considered an adequate standard of care. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. Thus, vendors targeting foreign-language speakers in the United States would have been missed. Although the vast majority of websites were in English, some were in other languages. Recent evidence in ethnic communities in the United States indicates a high level of self-medication with antibiotics either obtained without a prescription in a foreign country and imported into the United States or acquired in the United States without a prescription at stores in ethnic communities. Further education aimed at patients and the community, as well as increased regulation and application of existing guidelines, can help control this potentially vast reservoir of antibiotics. The frequency of relevant Web sites declined substantially after the first 300. Increased regulation of sites outside of controlled substances to include antibiotics seems guaranteed and necessary. After completing the online medical history, the customer would be given a prescription that would allow the purchase to be completed. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. The findings described in this study suggest that there is a potentially large pool of antibiotics in the United States that is not affected by initiatives to change physician-prescribing practices and may be contributing to antibiotic resistance. Finally, in order to determine whether these sites actually provide a product that they intended to sell over the counter, we submitted an online order to 1 vendor for 6 tablets of azithromycin, 500 mg each.

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