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First, this study provides a sample of websites and providers, and thus may not be indicative of all suppliers selling over-the-counter antibiotics. In the case of online histories to justify a prescription, we assumed that individuals are primarily purchasing antibiotics for an acute problem. After completing the online medical history, the customer would be given a prescription that would allow the purchase to be completed. 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, other disturbing evidence suggests that this problem may not be easily fixed through education, a troubling issue in controlling antibiotic use. Patients are increasingly using the Internet not only to access health information but also to obtain medication. As websites appear and disappear at a relative frequency, searches and classifications were performed during the first week of September 2008. 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. The frequency of relevant Web sites declined substantially after the first 300. Because of its effect on morbidity and mortality, antibiotic resistance is considered a threat to US health and national security by the Institute of Medicine and the Infectious Diseases Society of America. Reducing inappropriate use of antibiotics is key to many antibiotic resistance initiatives. Other providers are trying to upset this law by providing online diagnoses and prescriptions based on medical records without a physical examination and without a long relationship between the patient and the doctor, a practice that is not considered an adequate standard of care. 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. This study was not meant to be an exhaustive census of these sites, primarily because with the questionable legality of some of these practices, these sites rapidly come and go. 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.

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