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The extent to which antibiotics are available for over-the-counter purchases over the Internet is unknown. 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. This practice also occurs in the United States even though the United States regulates the acquisition of antibiotics, which will be limited by prescription only. 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. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. 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. Specifically, we classified a single course of azithromycin as 6 pills, 250 mg each. The frequency of relevant Web sites declined substantially after the first 300. In the case of online histories to justify a prescription, we assumed that individuals are primarily purchasing antibiotics for an acute problem. First, this study provides a sample of websites and providers, and thus may not be indicative of all suppliers selling over-the-counter antibiotics. 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. Further education aimed at patients and the community, as well as increased regulation and application of existing guidelines, can help control this potentially vast reservoir of antibiotics. The purpose of this study was to examine antibiotics available to patients without a prescription, a phenomenon on the Internet. Fourth, we have limited our count to English language websites. First, although all of the included providers would sell antibiotics without a prescription, we assessed whether the supplier would sell antibiotics without any form of prescription or whether a prescription created for the purchase based on the completion of an online medical history was required. 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.

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