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First, although all of the included providers would sell antibiotics without a prescription, we assessed whether the supplier would sell antibiotics without any form of prescription or whether a prescription created for the purchase based on the completion of an online medical history was required. If those who are self-medicating are taught that they put their own health at risk, they may be less likely to use these online pharmacies. Although excessive consumption of antibiotics has contributed to the spread of antibiotic resistance, 4-6 most initiatives regarding inappropriate direct human consumption of the antibiotic therapy center are almost exclusively controlled by prescribing by healthcare clinicians. Finally, and potentially the biggest limitation on the importance of this study, is that we were unable to describe how this Internet-based purchasing strategy was used to purchase people with antibiotics in the United States. For example, we found that servers at Dartmouth College, East Carolina University, University of Pittsburgh, Carnegie Mellon University, and California State University in San Francisco were all used, most likely without their knowledge, to be reassigned to online pharmacies. Clinicians evaluating the patient's use of self-medication when taking a medical history may function as an important opportunity to tell patients about not only antibiotic resistance, but also potential interactions between antibiotics and other prescription drugs. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. Third, we categorized the classes of antibiotics available for purchase. Although providing over-the-counter drugs is illegal in the United States, failure to enforce US laws likely encourages these companies to sell their products to patients. There are several limitations to this study. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. The purpose of this study was to examine antibiotics available to patients without a prescription, a phenomenon on the Internet. Our study suggests that the opposite might be the case. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. We compared identifying telephone numbers, street addresses, and site headers for each site as a way to sort out duplication.

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