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This decrease was interpreted as evidence that the full use of antibiotics was also reduced. 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. 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. In our analysis of evidence of the concept of buying 6 tablets of azithromycin, 500 mg each. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. As some vendors have multiple URLs to reach their company, we checked the mailing address, title and phone number to avoid double counting. 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. The extended delay between diagnosis and treatment receipt has consequences for resolving self-limiting conditions and storing unused treatment. Patients are increasingly using the Internet not only to access health information but also to obtain medication. The findings described in this study suggest that there is a potentially large pool of antibiotics in the United States that is not affected by initiatives to change physician-prescribing practices and may be contributing to antibiotic resistance. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. 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. Our final list of URLs included 184 links to single vendors of antibiotics. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. Thus, vendors targeting foreign-language speakers in the United States would have been missed.

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