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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. This study was not meant to be an exhaustive census of these sites, primarily because with the questionable legality of some of these practices, these sites rapidly come and go. Fifth, we estimated the expected delivery time to take antibiotics. Thus, as soon as patients receive over-the-counter antibiotics and self-treating self-limiting illnesses with drugs, such as upper-respiratory tract infections without complications, they are likely to suggest that the antibiotic was effective, and self-medicate in the future. We considered more than 6 pills to be excessive and could lead to future self-medication with the unused pills. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. In addition, the ability of Internet-based companies to exist without an identifiable physical location or property makes the location and writing of FDA instructions extremely difficult. As a result, most community assessments of antibiotic reservoirs are based on assessments by prescribing clinician behavior. 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. In the case of online histories to justify a prescription, we assumed that individuals are primarily purchasing antibiotics for an acute problem. Thus, vendors targeting foreign-language speakers in the United States would have been missed. 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. Our study suggests that the opposite might be the case. The first 300 search results of on both sites were examined to identify vendors for antibiotics that did not require a prescription. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated.

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