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The first 300 search results of on both sites were examined to identify vendors for antibiotics that did not require a prescription. No prescription was required, and no online consultation was necessary. Patients are increasingly using the Internet not only to access health information but also to obtain medication. 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. In usual face-to-face health care visits for respiratory tract infections during which antibiotics are prescribed, more than 90% of prescriptions are filled on the day of the office visit. Third, we could not to determine how often pharmaceuticals purchased over the Internet were not genuine, inactive, out of date, or adulterated. 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. That these companies can be located in countries outside US jurisdictions complicates enforcement of US laws. 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. 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. 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. 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. 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. Moreover, pharmaceutical companies may need to monitor who is selling their products and through what mechanisms. 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. Unfortunately, other disturbing evidence suggests that this problem may not be easily fixed through education, a troubling issue in controlling antibiotic use.

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