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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. 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. Specifically, we classified a single course of azithromycin as 6 pills, 250 mg each. Third, we categorized the classes of antibiotics available for purchase. Although the vast majority of websites were in English, some were in other languages. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. Increased regulation of sites outside of controlled substances to include antibiotics seems guaranteed and necessary. 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. As a result, most community assessments of antibiotic reservoirs are based on assessments by prescribing clinician behavior. If those who are self-medicating are taught that they put their own health at risk, they may be less likely to use these online pharmacies. As websites appear and disappear at a relative frequency, searches and classifications were performed during the first week of September 2008. This phenomenon has not been the focus of initiatives to control antibiotic resistance. Previous research suggests that a patient's past experience of care seeking and treatment use influences future expectations for treatment of respiratory tract infections. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. 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. 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.

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