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As a result, most community assessments of antibiotic reservoirs are based on assessments by prescribing clinician behavior. Self-administration of antibiotics occurs in all countries, but it is particularly problematic where the use of antimicrobials without a prescription is encouraged by the lack of laws restricting antibiotic sales or a failure to enforce the laws. 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. 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. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. European countries struggled with the problem of self-medication with antibiotics and found that the belief in the appropriateness of self-medication with antibiotics for bronchitis and the perceived availability of antibiotics without a prescription was associated with an increased likelihood of self-medication. The extended delay between diagnosis and treatment receipt has consequences for resolving self-limiting conditions and storing unused treatment. First, although all of the included providers would sell antibiotics without a prescription, we assessed whether the supplier would sell antibiotics without any form of prescription or whether a prescription created for the purchase based on the completion of an online medical history was required. All these obstacles cause the illegal acquisition of antibiotics by patients. 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. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. 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. 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. Even with these strategies, however, it was difficult to know whether one corporation still owns and manages several locations.

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