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There are several limitations to this study. Thus, vendors targeting foreign-language speakers in the United States would have been missed. 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 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. Fourth, we have limited our count to English language websites. 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. This phenomenon has not been the focus of initiatives to control antibiotic resistance. 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. 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. As part of this study, we bought over-the-counter antibiotics over the counter. 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. For this second group, no prescription from a doctor or clinical physician was necessary before gaining access to the site. Several studies suggest that antibiotic prescribing for viral illnesses, respiratory tract infections being one example, has declined in the last decade. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act.

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