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For this second group, no prescription from a doctor or clinical physician was necessary before gaining access to the site. This decrease was interpreted as evidence that the full use of antibiotics was also reduced. Our study suggests that the opposite might be the case. 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. 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. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. 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. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. 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. Although excessive consumption of antibiotics has contributed to the spread of antibiotic resistance, 4-6 most initiatives regarding inappropriate direct human consumption of the antibiotic therapy center are almost exclusively controlled by prescribing by healthcare clinicians. 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). Unfortunately, this strategy of focusing on prescribing practices does not address the behavior of self-medication with antibiotics. 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. In the case of online histories to justify a prescription, we assumed that individuals are primarily purchasing antibiotics for an acute problem. 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, 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.

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