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This phenomenon has not been the focus of initiatives to control antibiotic resistance. No prescription was required, and no online consultation was necessary. The frequency of relevant Web sites declined substantially after the first 300. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. The extended delay between diagnosis and treatment receipt has consequences for resolving self-limiting conditions and storing unused treatment. 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. 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. In some cases the URL did not take the reader to an actual medication vendor; rather, the Web site contained multiple advertisements and links to other sites for purchasing antibiotics. Several studies suggest that antibiotic prescribing for viral illnesses, respiratory tract infections being one example, has declined in the last decade. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. 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. 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. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. Even with these strategies, however, it was difficult to know whether one corporation still owns and manages several locations. This activity suggests that some vendors are aware of the questionable legitimacy of their business.

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