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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. In addition, the available quantities and the interval between prescribing and receiving treatment suggest that these transactions will likely be used by people storing drugs for future self-diagnosis and treatment, or for sale. Although the vast majority of websites were in English, some were in other languages. The vendors identified in this study do not appear to be fearful of prosecution. The purpose of this study was to examine antibiotics available to patients without a prescription, a phenomenon on the Internet. 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. 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. 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. This practice also occurs in the United States even though the United States regulates the acquisition of antibiotics, which will be limited by prescription only. Our study suggests that the opposite might be the case. Even with these strategies, however, it was difficult to know whether one corporation still owns and manages several locations. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. 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 extent to which antibiotics are available for over-the-counter purchases over the Internet is unknown. 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. This activity suggests that some vendors are aware of the questionable legitimacy of their business.

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