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Second, there was a considerable repetition in the Web sites, which made an accurate determination of unique vendors from the 184 different sites difficult, an effort that may have let to some error. For this second group, no prescription from a doctor or clinical physician was necessary before gaining access to the site. 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. Increased regulation of sites outside of controlled substances to include antibiotics seems guaranteed and necessary. The vendors identified in this study do not appear to be fearful of prosecution. As a result, most community assessments of antibiotic reservoirs are based on assessments by prescribing clinician behavior. The frequency of relevant Web sites declined substantially after the first 300. 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. The first 300 search results of on both sites were examined to identify vendors for antibiotics that did not require a prescription. Our final list of URLs included 184 links to single vendors of antibiotics. 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 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. 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. 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, 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.

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