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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. 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. There are several limitations to this study. 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. 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 extent to which antibiotics are available for over-the-counter purchases over the Internet is unknown. Although the vast majority of websites were in English, some were in other languages. This phenomenon has not been the focus of initiatives to control antibiotic resistance. European countries struggled with the problem of self-medication with antibiotics and found that the belief in the appropriateness of self-medication with antibiotics for bronchitis and the perceived availability of antibiotics without a prescription was associated with an increased likelihood of self-medication. Moreover, pharmaceutical companies may need to monitor who is selling their products and through what mechanisms. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. Unfortunately, this strategy of focusing on prescribing practices does not address the behavior of self-medication with antibiotics. We considered more than 6 pills to be excessive and could lead to future self-medication with the unused pills. 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. To examine the types of Web sites and vendors dispensing antibiotics on the Internet, we conducted a search using 2 major search engines (Google and Yahoo) and the key words "purchase antibiotics without prescription" and "online (English only).

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