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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. We compared identifying telephone numbers, street addresses, and site headers for each site as a way to sort out duplication. 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. 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. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. Recent evidence in ethnic communities in the United States indicates a high level of self-medication with antibiotics either obtained without a prescription in a foreign country and imported into the United States or acquired in the United States without a prescription at stores in ethnic communities. 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. Antibiotics serve a useful therapeutic purpose in treating and controlling the effects of infectious agents. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. Unfortunately, this strategy of focusing on prescribing practices does not address the behavior of self-medication with antibiotics. There are several limitations to this study. 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. Our study is the first to document this phenomenon, and we describe the mechanism for purchasing antibiotics online; future studies will need to document the scope of antibiotics purchased through this mechanism to better understand its direct implications for antibiotic resistance. 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. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time.

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