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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. This activity suggests that some vendors are aware of the questionable legitimacy of their business. Reducing inappropriate use of antibiotics is key to many antibiotic resistance initiatives. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. As websites appear and disappear at a relative frequency, searches and classifications were performed during the first week of September 2008. First, although all of the included providers would sell antibiotics without a prescription, we assessed whether the supplier would sell antibiotics without any form of prescription or whether a prescription created for the purchase based on the completion of an online medical history was required. 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. 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. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. 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). Previous research suggests that a patient's past experience of care seeking and treatment use influences future expectations for treatment of respiratory tract infections. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. After completing the online medical history, the customer would be given a prescription that would allow the purchase to be completed. 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. The extended delay between diagnosis and treatment receipt has consequences for resolving self-limiting conditions and storing unused treatment.

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