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Unfortunately, this strategy of focusing on prescribing practices does not address the behavior of self-medication with antibiotics. 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. Some Internet vendors also attempt to skirt US regulations by operating in countries outside the United States but marketing to US consumers. No prescription was required, and no online consultation was necessary. 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. 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. Finally, and potentially the biggest limitation on the importance of this study, is that we were unable to describe how this Internet-based purchasing strategy was used to purchase people with antibiotics in the United States. The frequency of relevant Web sites declined substantially after the first 300. First, although all of the included providers would sell antibiotics without a prescription, we assessed whether the supplier would sell antibiotics without any form of prescription or whether a prescription created for the purchase based on the completion of an online medical history was required. 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. 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. 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. Thus, vendors targeting foreign-language speakers in the United States would have been missed. Fifth, we estimated the expected delivery time to take antibiotics. 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.

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