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European countries struggled with the problem of self-medication with antibiotics and found that the belief in the appropriateness of self-medication with antibiotics for bronchitis and the perceived availability of antibiotics without a prescription was associated with an increased likelihood of self-medication. The extent to which antibiotics are available for over-the-counter purchases over the Internet is unknown. The purpose of this study was to examine antibiotics available to patients without a prescription, a phenomenon on the Internet. Previous research suggests that a patient's past experience of care seeking and treatment use influences future expectations for treatment of respiratory tract infections. 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. 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. The frequency of relevant Web sites declined substantially after the first 300. 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. For this second group, no prescription from a doctor or clinical physician was necessary before gaining access to the site. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. The vendors identified in this study do not appear to be fearful of prosecution. Our purchase arrived from Mexico with no information on instructions for use of the medication. This reservoir of antibiotics is likely to be used inappropriately-the Web sites promote self-diagnosis and self-medication, and antibiotics are likely to be used in inappropriate dosages. 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. 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. Increased regulation of sites outside of controlled substances to include antibiotics seems guaranteed and necessary.

Zichron Moshe School