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Finally, and potentially the biggest limitation on the importance of this study, is that we were unable to describe how this Internet-based purchasing strategy was used to purchase people with antibiotics in the United States. 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. As some vendors have multiple URLs to reach their company, we checked the mailing address, title and phone number to avoid double counting. For this second group, no prescription from a doctor or clinical physician was necessary before gaining access to the site. No prescription was required, and no online consultation was necessary. 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. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. 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. We compared identifying telephone numbers, street addresses, and site headers for each site as a way to sort out duplication. 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. 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. Reducing inappropriate use of antibiotics is key to many antibiotic resistance initiatives. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. The extended delay between diagnosis and treatment receipt has consequences for resolving self-limiting conditions and storing unused treatment.

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