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Moreover, pharmaceutical companies may need to monitor who is selling their products and through what mechanisms. As part of this study, we bought over-the-counter antibiotics over the counter. We compared identifying telephone numbers, street addresses, and site headers for each site as a way to sort out duplication. 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. 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). Thus, vendors targeting foreign-language speakers in the United States would have been missed. Increased regulation of sites outside of controlled substances to include antibiotics seems guaranteed and necessary. Reducing inappropriate use of antibiotics is key to many antibiotic resistance initiatives. 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. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. 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. First, this study provides a sample of websites and providers, and thus may not be indicative of all suppliers selling over-the-counter antibiotics. Our study suggests that the opposite might be the case. 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. 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. In addition, the ability of Internet-based companies to exist without an identifiable physical location or property makes the location and writing of FDA instructions extremely difficult.

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