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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. Although excessive consumption of antibiotics has contributed to the spread of antibiotic resistance, 4-6 most initiatives regarding inappropriate direct human consumption of the antibiotic therapy center are almost exclusively controlled by prescribing by healthcare clinicians. Thus, vendors targeting foreign-language speakers in the United States would have been missed. Even with these strategies, however, it was difficult to know whether one corporation still owns and manages several locations. This decrease was interpreted as evidence that the full use of antibiotics was also reduced. 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. All these obstacles cause the illegal acquisition of antibiotics by patients. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. Unfortunately, other disturbing evidence suggests that this problem may not be easily fixed through education, a troubling issue in controlling antibiotic use. This practice also occurs in the United States even though the United States regulates the acquisition of antibiotics, which will be limited by prescription only. 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. 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. As part of this study, we bought over-the-counter antibiotics over the counter. Our study suggests that the opposite might be the case. 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.

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