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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. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. Unfortunately, this strategy of focusing on prescribing practices does not address the behavior of self-medication with antibiotics. 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. Our study is the first to document this phenomenon, and we describe the mechanism for purchasing antibiotics online; future studies will need to document the scope of antibiotics purchased through this mechanism to better understand its direct implications for antibiotic resistance. Although the vast majority of websites were in English, some were in other languages. 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. To examine the types of Web sites and vendors dispensing antibiotics on the Internet, we conducted a search using 2 major search engines (Google and Yahoo) and the key words "purchase antibiotics without prescription" and "online (English only). Our study suggests that the opposite might be the case. Fifth, we estimated the expected delivery time to take antibiotics. The purpose of this study was to examine antibiotics available to patients without a prescription, a phenomenon on the Internet. As part of this study, we bought over-the-counter antibiotics over the counter. 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. Clinicians evaluating the patient's use of self-medication when taking a medical history may function as an important opportunity to tell patients about not only antibiotic resistance, but also potential interactions between antibiotics and other prescription drugs.

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