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There are several limitations to this study. As websites appear and disappear at a relative frequency, searches and classifications were performed during the first week of September 2008. Although more than half of the identified sites provided online consultation for prescribing, the lack of interaction between the patient and the doctor did not lead to any opportunity for patient education. Although the vast majority of websites were in English, some were in other languages. Patients are increasingly using the Internet not only to access health information but also to obtain medication. 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. All these obstacles cause the illegal acquisition of antibiotics by patients. The extent to which antibiotics are available for over-the-counter purchases over the Internet is unknown. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. In the case of online histories to justify a prescription, we assumed that individuals are primarily purchasing antibiotics for an acute problem. The first 300 search results of on both sites were examined to identify vendors for antibiotics that did not require a prescription. 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. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. 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 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. 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.

Assistance League of Southern California
Bethany Lutheran School