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In conclusion, antibiotics are freely available for purchase over the Internet without a prescription, and the general structure of transactions encourages self-medication and poor quality care. 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. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. This decrease was interpreted as evidence that the full use of antibiotics was also reduced. Fourth, we have limited our count to English language websites. 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. 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. The US Food and Drug Administration forbids ordering prescription drugs from outside the United States: Thus, in virtually all instances, individual citizens are prohibited from importing prescription drugs into the United States. Finally, in order to determine whether these sites actually provide a product that they intended to sell over the counter, we submitted an online order to 1 vendor for 6 tablets of azithromycin, 500 mg each. For this second group, no prescription from a doctor or clinical physician was necessary before gaining access to the site. As a result, most community assessments of antibiotic reservoirs are based on assessments by prescribing clinician behavior. Increased regulation of sites outside of controlled substances to include antibiotics seems guaranteed and necessary. 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. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws.

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