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Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. For this second group, no prescription from a doctor or clinical physician was necessary before gaining access to the site. Fourth, we have limited our count to English language websites. In addition, the available quantities and the interval between prescribing and receiving treatment suggest that these transactions will likely be used by people storing drugs for future self-diagnosis and treatment, or for sale. Our study suggests that the opposite might be the case. Although providing over-the-counter drugs is illegal in the United States, failure to enforce US laws likely encourages these companies to sell their products to patients. This decrease was interpreted as evidence that the full use of antibiotics was also reduced. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. Other providers are trying to upset this law by providing online diagnoses and prescriptions based on medical records without a physical examination and without a long relationship between the patient and the doctor, a practice that is not considered an adequate standard of care. As websites appear and disappear at a relative frequency, searches and classifications were performed during the first week of September 2008. For example, we found that servers at Dartmouth College, East Carolina University, University of Pittsburgh, Carnegie Mellon University, and California State University in San Francisco were all used, most likely without their knowledge, to be reassigned to online pharmacies. Even with these strategies, however, it was difficult to know whether one corporation still owns and manages several locations. 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. Several studies suggest that antibiotic prescribing for viral illnesses, respiratory tract infections being one example, has declined in the last decade. As some vendors have multiple URLs to reach their company, we checked the mailing address, title and phone number to avoid double counting.

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