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Our final list of URLs included 184 links to single vendors of antibiotics. 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. In the case of online histories to justify a prescription, we assumed that individuals are primarily purchasing antibiotics for an acute problem. 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. No prescription was required, and no online consultation was necessary. Further education aimed at patients and the community, as well as increased regulation and application of existing guidelines, can help control this potentially vast reservoir of antibiotics. After completing the online medical history, the customer would be given a prescription that would allow the purchase to be completed. The extent to which antibiotics are available for over-the-counter purchases over the Internet is unknown. Second, there was a considerable repetition in the Web sites, which made an accurate determination of unique vendors from the 184 different sites difficult, an effort that may have let to some error. Although more than half of the identified sites provided online consultation for prescribing, the lack of interaction between the patient and the doctor did not lead to any opportunity for patient education. 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. The frequency of relevant Web sites declined substantially after the first 300. As some vendors have multiple URLs to reach their company, we checked the mailing address, title and phone number to avoid double counting. In usual face-to-face health care visits for respiratory tract infections during which antibiotics are prescribed, more than 90% of prescriptions are filled on the day of the office visit. Specifically, we classified a single course of azithromycin as 6 pills, 250 mg each. The medical community and the public health and regulating agencies, as well as pharmaceutical companies, need to expand efforts to control antibiotic resistance beyond initiatives centered on prescribing behavior to include self-medication and sources of antibiotics obtained without prescription.

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