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Even with these strategies, however, it was difficult to know whether one corporation still owns and manages several locations. Thus, as soon as patients receive over-the-counter antibiotics and self-treating self-limiting illnesses with drugs, such as upper-respiratory tract infections without complications, they are likely to suggest that the antibiotic was effective, and self-medicate in the future. As part of this study, we bought over-the-counter antibiotics over the counter. 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. 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. 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. 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. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. For this second group, no prescription from a doctor or clinical physician was necessary before gaining access to the site. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. 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. This phenomenon has not been the focus of initiatives to control antibiotic resistance. 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. In the case of online histories to justify a prescription, we assumed that individuals are primarily purchasing antibiotics for an acute problem.

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