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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. Unfortunately, this strategy of focusing on prescribing practices does not address the behavior of self-medication with antibiotics. As part of this study, we bought over-the-counter antibiotics over the counter. Finally, and potentially the biggest limitation on the importance of this study, is that we were unable to describe how this Internet-based purchasing strategy was used to purchase people with antibiotics in the United States. Our purchase arrived from Mexico with no information on instructions for use of the medication. This activity suggests that some vendors are aware of the questionable legitimacy of their business. 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. To examine the types of Web sites and vendors dispensing antibiotics on the Internet, we conducted a search using 2 major search engines (Google and Yahoo) and the key words "purchase antibiotics without prescription" and "online (English only). 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. Although providing over-the-counter drugs is illegal in the United States, failure to enforce US laws likely encourages these companies to sell their products to patients. Our final list of URLs included 184 links to single vendors of antibiotics. The frequency of relevant Web sites declined substantially after the first 300. Because of its effect on morbidity and mortality, antibiotic resistance is considered a threat to US health and national security by the Institute of Medicine and the Infectious Diseases Society of America. The US Food and Drug Administration forbids ordering prescription drugs from outside the United States: Thus, in virtually all instances, individual citizens are prohibited from importing prescription drugs into the United States. Specifically, we classified a single course of azithromycin as 6 pills, 250 mg each.

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