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If patients who are now denied antibiotics through their physician can access over-the-counter medications, the overall level of antibiotic use in the general population can actually increase and thus have a significant effect on rates of resistance to microbial degradation. Fifth, we estimated the expected delivery time to take antibiotics. 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. Thus, vendors targeting foreign-language speakers in the United States would have been missed. The frequency of relevant Web sites declined substantially after the first 300. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. 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. This reservoir of antibiotics is likely to be used inappropriately-the Web sites promote self-diagnosis and self-medication, and antibiotics are likely to be used in inappropriate dosages. This decrease was interpreted as evidence that the full use of antibiotics was also reduced. Although the vast majority of websites were in English, some were in other languages. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. Moreover, pharmaceutical companies may need to monitor who is selling their products and through what mechanisms. 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. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. 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.

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