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Self-administration of antibiotics occurs in all countries, but it is particularly problematic where the use of antimicrobials without a prescription is encouraged by the lack of laws restricting antibiotic sales or a failure to enforce the laws. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. 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. Unfortunately, this strategy of focusing on prescribing practices does not address the behavior of self-medication with antibiotics. Third, we categorized the classes of antibiotics available for purchase. The medical community and the public health and regulating agencies, as well as pharmaceutical companies, need to expand efforts to control antibiotic resistance beyond initiatives centered on prescribing behavior to include self-medication and sources of antibiotics obtained without prescription. The frequency of relevant Web sites declined substantially after the first 300. We classified Web sites of vendors according to several variables. 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. Unfortunately, other disturbing evidence suggests that this problem may not be easily fixed through education, a troubling issue in controlling antibiotic use. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. As some vendors have multiple URLs to reach their company, we checked the mailing address, title and phone number to avoid double counting. This reservoir of antibiotics is likely to be used inappropriately-the Web sites promote self-diagnosis and self-medication, and antibiotics are likely to be used in inappropriate dosages. In addition, the ability of Internet-based companies to exist without an identifiable physical location or property makes the location and writing of FDA instructions extremely difficult. 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.

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