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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 vendors identified in this study do not appear to be fearful of prosecution. 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. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. 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. The purpose of this study was to examine antibiotics available to patients without a prescription, a phenomenon on the Internet. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. Second, we examined whether the vendor would ship prescription antibiotics to a buyer in the United States, as well as several other countries (Canada, United Kingdom) where antibiotics are available only by prescription. The frequency of relevant Web sites declined substantially after the first 300. In usual face-to-face health care visits for respiratory tract infections during which antibiotics are prescribed, more than 90% of prescriptions are filled on the day of the office visit. 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. Recent evidence in ethnic communities in the United States indicates a high level of self-medication with antibiotics either obtained without a prescription in a foreign country and imported into the United States or acquired in the United States without a prescription at stores in ethnic communities. Several studies suggest that antibiotic prescribing for viral illnesses, respiratory tract infections being one example, has declined in the last decade. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. This reservoir of antibiotics is likely to be used inappropriately-the Web sites promote self-diagnosis and self-medication, and antibiotics are likely to be used in inappropriate dosages.

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