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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. In conclusion, antibiotics are freely available for purchase over the Internet without a prescription, and the general structure of transactions encourages self-medication and poor quality care. 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. Unfortunately, other disturbing evidence suggests that this problem may not be easily fixed through education, a troubling issue in controlling antibiotic use. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. Specifically, we classified a single course of azithromycin as 6 pills, 250 mg each. 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. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. 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. There are several limitations to this study. Reducing inappropriate use of antibiotics is key to many antibiotic resistance initiatives. As part of this study, we bought over-the-counter antibiotics over the counter. We classified Web sites of vendors according to several variables. We assessed whether individuals could purchase penicillins, macrolides, fluoroquinolones, and cephalosporins, because the availability of multiple classes of antibiotics would affect additional selective pressure in the community. Patients are increasingly using the Internet not only to access health information but also to obtain medication. Although the vast majority of websites were in English, some were in other languages.

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