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Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. We considered more than 6 pills to be excessive and could lead to future self-medication with the unused pills. The frequency of relevant Web sites declined substantially after the first 300. 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. In some cases the URL did not take the reader to an actual medication vendor; rather, the Web site contained multiple advertisements and links to other sites for purchasing antibiotics. 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. 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 websites appear and disappear at a relative frequency, searches and classifications were performed during the first week of September 2008. 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. 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. In the case of online histories to justify a prescription, we assumed that individuals are primarily purchasing antibiotics for an acute problem. Although the vast majority of websites were in English, some were in other languages. The first 300 search results of on both sites were examined to identify vendors for antibiotics that did not require a prescription. 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 links to these advertised sites were also investigated. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers.

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