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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. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. Some prescription medication is sold without a valid prescription, which is a violation of the Federal Food, Drug, and Cosmetic Act. This activity suggests that some vendors are aware of the questionable legitimacy of their business. Second, we examined whether the vendor would ship prescription antibiotics to a buyer in the United States, as well as several other countries (Canada, United Kingdom) where antibiotics are available only by prescription. 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. 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. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. 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. European countries struggled with the problem of self-medication with antibiotics and found that the belief in the appropriateness of self-medication with antibiotics for bronchitis and the perceived availability of antibiotics without a prescription was associated with an increased likelihood of self-medication. 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). 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. Reducing inappropriate use of antibiotics is key to many antibiotic resistance initiatives. Although more than half of the identified sites provided online consultation for prescribing, the lack of interaction between the patient and the doctor did not lead to any opportunity for patient education. Third, we categorized the classes of antibiotics available for purchase. 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.

St Mary S School