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The vendors identified in this study do not appear to be fearful of prosecution. In conclusion, antibiotics are freely available for purchase over the Internet without a prescription, and the general structure of transactions encourages self-medication and poor quality care. If those who are self-medicating are taught that they put their own health at risk, they may be less likely to use these online pharmacies. Our final list of URLs included 184 links to single vendors of antibiotics. As websites appear and disappear at a relative frequency, searches and classifications were performed during the first week of September 2008. In the case of online histories to justify a prescription, we assumed that individuals are primarily purchasing antibiotics for an acute problem. 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. Several studies suggest that antibiotic prescribing for viral illnesses, respiratory tract infections being one example, has declined in the last decade. 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. No prescription was required, and no online consultation was necessary. Thus, vendors targeting foreign-language speakers in the United States would have been missed. Since the websites suggested a range of days for the expected treatment receipt, we used the median to represent the expected delivery time. 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. For example, we found that servers at Dartmouth College, East Carolina University, University of Pittsburgh, Carnegie Mellon University, and California State University in San Francisco were all used, most likely without their knowledge, to be reassigned to online pharmacies. 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.

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