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Unfortunately, this strategy of focusing on prescribing practices does not address the behavior of self-medication with antibiotics. This phenomenon has not been the focus of initiatives to control antibiotic resistance. In conclusion, antibiotics are freely available for purchase over the Internet without a prescription, and the general structure of transactions encourages self-medication and poor quality care. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. In some cases the URL did not take the reader to an actual medication vendor; rather, the Web site contained multiple advertisements and links to other sites for purchasing antibiotics. We compared identifying telephone numbers, street addresses, and site headers for each site as a way to sort out duplication. 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. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. 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. Second, there was a considerable repetition in the Web sites, which made an accurate determination of unique vendors from the 184 different sites difficult, an effort that may have let to some error. 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. In the case of online histories to justify a prescription, we assumed that individuals are primarily purchasing antibiotics for an acute problem. 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. We therefore wanted to find out if the amount of time between online evaluation and getting treatment was significantly longer. Reducing inappropriate use of antibiotics is key to many antibiotic resistance initiatives.

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