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Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. As websites appear and disappear at a relative frequency, searches and classifications were performed during the first week of September 2008. Third, we categorized the classes of antibiotics available for purchase. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. 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 links to these advertised sites were also investigated. 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. 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. The vendors identified in this study do not appear to be fearful of prosecution. Thus, vendors targeting foreign-language speakers in the United States would have been missed. Our study suggests that the opposite might be the case. As some vendors have multiple URLs to reach their company, we checked the mailing address, title and phone number to avoid double counting. 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. 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.

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