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The links to these advertised sites were also investigated. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. In addition, the ability of Internet-based companies to exist without an identifiable physical location or property makes the location and writing of FDA instructions extremely difficult. The US Food and Drug Administration forbids ordering prescription drugs from outside the United States: Thus, in virtually all instances, individual citizens are prohibited from importing prescription drugs into the United States. We considered more than 6 pills to be excessive and could lead to future self-medication with the unused pills. Although the vast majority of websites were in English, some were in other languages. Third, we categorized the classes of antibiotics available for purchase. 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. 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. If those who are self-medicating are taught that they put their own health at risk, they may be less likely to use these 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. 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. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. Second, we examined whether the vendor would ship prescription antibiotics to a buyer in the United States, as well as several other countries (Canada, United Kingdom) where antibiotics are available only by prescription. In usual face-to-face health care visits for respiratory tract infections during which antibiotics are prescribed, more than 90% of prescriptions are filled on the day of the office visit. First, this study provides a sample of websites and providers, and thus may not be indicative of all suppliers selling over-the-counter antibiotics.

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