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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. 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. Self-administration of antibiotics occurs in all countries, but it is particularly problematic where the use of antimicrobials without a prescription is encouraged by the lack of laws restricting antibiotic sales or a failure to enforce the laws. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. We classified Web sites of vendors according to several variables. Our study suggests that the opposite might be the case. 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. 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. Fourth, we have limited our count to English language websites. We considered more than 6 pills to be excessive and could lead to future self-medication with the unused pills. This activity suggests that some vendors are aware of the questionable legitimacy of their business. Unfortunately, other disturbing evidence suggests that this problem may not be easily fixed through education, a troubling issue in controlling antibiotic use. Clinicians evaluating the patient's use of self-medication when taking a medical history may function as an important opportunity to tell patients about not only antibiotic resistance, but also potential interactions between antibiotics and other prescription drugs. 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. 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.

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