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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. As part of this study, we bought over-the-counter antibiotics over the counter. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. Our purchase arrived from Mexico with no information on instructions for use of the medication. Unfortunately, other disturbing evidence suggests that this problem may not be easily fixed through education, a troubling issue in controlling antibiotic use. 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. Although the vast majority of websites were in English, some were in other languages. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. Thus, vendors targeting foreign-language speakers in the United States would have been missed. Specifically, we classified a single course of azithromycin as 6 pills, 250 mg each. The links to these advertised sites were also investigated. We assessed whether individuals could purchase penicillins, macrolides, fluoroquinolones, and cephalosporins, because the availability of multiple classes of antibiotics would affect additional selective pressure in the community. Fourth, we categorized whether a person could buy antibiotics, especially broad-spectrum antibiotics, in quantities greater than what would be considered adequate 1 course of treatment for acute respiratory tract infection. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. The frequency of relevant Web sites declined substantially after the first 300.

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