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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. The vendors identified in this study do not appear to be fearful of prosecution. 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. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. 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. Thus, as soon as patients receive over-the-counter antibiotics and self-treating self-limiting illnesses with drugs, such as upper-respiratory tract infections without complications, they are likely to suggest that the antibiotic was effective, and self-medicate in the future. This reservoir of antibiotics is likely to be used inappropriately-the Web sites promote self-diagnosis and self-medication, and antibiotics are likely to be used in inappropriate dosages. Self-administration of antibiotics occurs in all countries, but it is particularly problematic where the use of antimicrobials without a prescription is encouraged by the lack of laws restricting antibiotic sales or a failure to enforce the laws. 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. Even with these strategies, however, it was difficult to know whether one corporation still owns and manages several locations. 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. 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 categorized whether a person could buy antibiotics, especially broad-spectrum antibiotics, in quantities greater than what would be considered adequate 1 course of treatment for acute respiratory tract infection. 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. For this second group, no prescription from a doctor or clinical physician was necessary before gaining access to the site.

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