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The links to these advertised sites were also investigated. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. 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. 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. Increased regulation of sites outside of controlled substances to include antibiotics seems guaranteed and necessary. 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. 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. This activity suggests that some vendors are aware of the questionable legitimacy of their business. 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. Although excessive consumption of antibiotics has contributed to the spread of antibiotic resistance, 4-6 most initiatives regarding inappropriate direct human consumption of the antibiotic therapy center are almost exclusively controlled by prescribing by healthcare clinicians. As some vendors have multiple URLs to reach their company, we checked the mailing address, title and phone number to avoid double counting. 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. Even with these strategies, however, it was difficult to know whether one corporation still owns and manages several locations.

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