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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. Reducing inappropriate use of antibiotics is key to many antibiotic resistance initiatives. We assessed whether individuals could purchase penicillins, macrolides, fluoroquinolones, and cephalosporins, because the availability of multiple classes of antibiotics would affect additional selective pressure in the community. We compared identifying telephone numbers, street addresses, and site headers for each site as a way to sort out duplication. We classified Web sites of vendors according to several variables. As some vendors have multiple URLs to reach their company, we checked the mailing address, title and phone number to avoid double counting. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. 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. Our final list of URLs included 184 links to single vendors of antibiotics. Recent evidence in ethnic communities in the United States indicates a high level of self-medication with antibiotics either obtained without a prescription in a foreign country and imported into the United States or acquired in the United States without a prescription at stores in ethnic communities. Although the vast majority of websites were in English, some were in other languages. 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. 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. 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. Moreover, pharmaceutical companies may need to monitor who is selling their products and through what mechanisms. 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.

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