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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. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. Antibiotic resistance is a common problem, however, and has been described with numerous infectious agents and in varying contexts. Our final list of URLs included 184 links to single vendors of antibiotics. We considered more than 6 pills to be excessive and could lead to future self-medication with the unused pills. Thus, vendors targeting foreign-language speakers in the United States would have been missed. 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. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. Fifth, we estimated the expected delivery time to take antibiotics. 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. After completing the online medical history, the customer would be given a prescription that would allow the purchase to be completed. For this second group, no prescription from a doctor or clinical physician was necessary before gaining access to the site. 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. Other providers are trying to upset this law by providing online diagnoses and prescriptions based on medical records without a physical examination and without a long relationship between the patient and the doctor, a practice that is not considered an adequate standard of care. 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).

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