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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. 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. 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. 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 the vast majority of websites were in English, some were in other languages. Other providers are trying to upset this law by providing online diagnoses and prescriptions based on medical records without a physical examination and without a long relationship between the patient and the doctor, a practice that is not considered an adequate standard of care. This reservoir of antibiotics is likely to be used inappropriately-the Web sites promote self-diagnosis and self-medication, and antibiotics are likely to be used in inappropriate dosages. No prescription was required, and no online consultation was necessary. Specifically, we classified a single course of azithromycin as 6 pills, 250 mg each. Our final list of URLs included 184 links to single vendors of antibiotics. 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. The first 300 search results of on both sites were examined to identify vendors for antibiotics that did not require a prescription. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. If patients who are now denied antibiotics through their physician can access over-the-counter medications, the overall level of antibiotic use in the general population can actually increase and thus have a significant effect on rates of resistance to microbial degradation. 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.

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