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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. Fourth, we have limited our count to English language websites. To examine the types of Web sites and vendors dispensing antibiotics on the Internet, we conducted a search using 2 major search engines (Google and Yahoo) and the key words "purchase antibiotics without prescription" and "online (English only). Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. Unfortunately, this strategy of focusing on prescribing practices does not address the behavior of self-medication with antibiotics. Although more than half of the identified sites provided online consultation for prescribing, the lack of interaction between the patient and the doctor did not lead to any opportunity for patient education. The medical community and the public health and regulating agencies, as well as pharmaceutical companies, need to expand efforts to control antibiotic resistance beyond initiatives centered on prescribing behavior to include self-medication and sources of antibiotics obtained without prescription. The first 300 search results of on both sites were examined to identify vendors for antibiotics that did not require a prescription. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. In our analysis of evidence of the concept of buying 6 tablets of azithromycin, 500 mg each. Specifically, we classified a single course of azithromycin as 6 pills, 250 mg each. 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. First, this study provides a sample of websites and providers, and thus may not be indicative of all suppliers selling over-the-counter antibiotics. This decrease was interpreted as evidence that the full use of antibiotics was also reduced. The extended delay between diagnosis and treatment receipt has consequences for resolving self-limiting conditions and storing unused treatment.

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