Candida albicans-A systematic review to inform the World Health Organization Fungal Priority Pathogens List.

Candida albicans is a common fungal pathogen and amongst the leading causes of invasive candidiasis globally. This systematic review examines the characteristics and global impact of invasive infections caused by C. albicans. We searched on PubMed and Web of Science for studies reporting on criteria such as mortality, morbidity, drug resistance, preventability, yearly incidence, and distribution/emergence during the period from 2016 to 2021. Our findings indicate that C. albicans is the most common Candida species causing invasive disease and that standard infection control measures are the primary means of prevention. However, we found high rates of mortality associated with infections caused by C. albicans. Furthermore, there is a lack of data on complications and sequelae. Resistance to commonly used antifungals remains rare. Although, whilst generally susceptible to azoles, we found some evidence of increasing resistance, particularly in middle-income settings-notably, data from low-income settings were limited. Candida albicans remains susceptible to echinocandins, amphotericin B, and flucytosine. We observed evidence of a decreasing proportion of infections caused by C. albicans relative to other Candida species, although detailed epidemiological studies are needed to confirm this trend. More robust data on attributable mortality, complications, and sequelae are needed to understand the full extent of the impact of invasive C. albicans infections.

Health system barriers to the implementation of the national action plan to combat antimicrobial resistance in Vietnam: a scoping review.

BACKGROUND: Vietnam is among 11 countries in the Western Pacific region that has developed a National Action Plan for Antimicrobial Resistance (NAPCA). METHODS: This scoping review characterises health system barriers to the implementation of the Vietnam NAPCA, with reference to the WHO Health Systems Framework. RESULTS: Over 7 years, between 2013 and 2020, the Ministry of Health (MOH) of Vietnam has been implementing activities to achieve the six NAPCA objectives. They include revision of regulations needed for antimicrobial resistance (AMR) prevention programs; formation and operation of national management bodies; improvement of antimicrobial stewardship (AMS) in hospitals; maintenance of surveillance systems for AMR; provision of trainings on AMR and antibiotics use to doctors and pharmacists; and organization of nation-wide educational campaigns. Limited cooperation between MOH management bodies, shortages of human resource at all health system levels, a low degree of agreement between national and hospital guidelines on antibiotic use, low capability in the domestic supply of standardised drugs, and unequal training opportunities for lower-level health professionals present ongoing challenges. Actions suggested for the next period of the NAPCA include a final review of what has been achieved by the plan so far and evaluating the effectiveness of the different components of the plan. Different options on how to improve coordination across sectors in the development of a new NAPCA should be put forward. CONCLUSIONS: The 6-year implementation of the Vietnam NAPCA has yielded valuable lessons for AMS in Vietnam, guiding the development of future national plans, with a central focus on scaling up AMS in hospitals and promoting community AMS programs to combat AMR.

Effectiveness of antismoking media messages and education among adolescents in Malaysia and Thailand: findings from the international tobacco control southeast Asia project.

INTRODUCTION: Finding ways to discourage adolescents from taking up smoking is important because those who begin smoking at an earlier age are more likely to become addicted and have greater difficulty in quitting. This article examined whether anti smoking messages and education could help to reduce smoking susceptibility among adolescents in two Southeast Asian countries and to explore the possible moderating effect of country and gender. METHODS: Data came from Wave 1 of the International Tobacco Control Southeast Asia Project (ITC-SEA) survey conducted in Malaysia (n = 1,008) and Thailand (n = 1,000) where adolescents were asked about receiving antismoking advice from nurses or doctors, being taught at schools about the danger of smoking, noticing antismoking messages, knowledge of health effects of smoking, beliefs about the health risks of smoking, smoking susceptibility, and demographic information. Data were analyzed using chi-square tests and logistic regression models. RESULTS: Overall, significantly more Thai adolescents reported receiving advice from their nurses or doctors about the danger of smoking (p < .001), but no country difference was observed for reported antismoking education in schools and exposure to antismoking messages. Multivariate analyses revealed that only provision of antismoking education at schools was significantly associated with reduced susceptibility to smoking among female Malaysian adolescents (OR = 0.26). Higher knowledge of smoking harm and higher perceived health risk of smoking were associated with reduced smoking susceptibility among Thai female (OR = 0.52) and Malaysian male adolescents (OR = 0.63), respectively. CONCLUSIONS: Educating adolescents about the dangers of smoking in schools appears to be the most effective means of reducing adolescents' smoking susceptibility in both countries, although different prevention strategies may be necessary to ensure effectiveness for male and female adolescents.

Identification of Confusing Medicine Proprietary Names: Toward Safe Medicine Use-A Cross-Sectional Study in Sri Lanka.

BACKGROUND: Look-alike sound-alike (LASA) medications have similar pronunciation (phonetic) and/or manifestation (orthographic), which could create confusion among users and challenge the safe use of medicines. The availability of foreign products in local markets aggravates the situation. This study was designed to examine the registered medicine proprietary names in Sri Lanka to discern the presence of similar medicine names in the industry. METHODS: A cross-sectional study was conducted on the registered drug proprietary names in Sri Lanka. Using the RAND and RANK functions in Microsoft® excel® 365, a random sample of 385 proprietary names was selected. Two evaluators independently evaluated each proprietary name in the sample against the other registered proprietary names following a stepwise text filtering method. After each filter, the resulting proprietary names were manually examined for identical, similar-looking, and similar-sounding proprietary names to the name under evaluation. The observations were matched, categorized, and collated into ten groups. RESULTS: Among the 385 names evaluated, 138 (35.84%) proprietary names had no similarity to existing other registered proprietary names. The rest of the names (n = 247, 64.15%) were found to be either identical (n = 03 pairs), look-alike (n = 91 pairs), or sound-alike (n = 80 pairs) to the registered proprietary names. CONCLUSION: The findings revealed the presence of equal and similar proprietary names in the system. A multifactorial strategy led by the National Medicine Regulatory Authority (NMRA) is recommended to minimize the confusing names entering the system. Primarily the NMRA's call for action should include adequate industry guidance with specific guidelines, a significant pre-submission assessment process, and denying approval of LASA proprietary names.

Mapping access to drug outlets in Vietnam: distribution of drug outlets and the sociodemographic characteristics of the communities they serve.

Background: Drug outlets are a vital first point of healthcare contact in low- and middle-income countries (LMICs), but they are often poorly regulated and counter staff may be unqualified to provide advice. This introduces the risk of easy access to potentially harmful products, including unnecessary antimicrobials. Over-the-counter antimicrobial sales are a major driver of antimicrobial resistance (AMR) in LMICs. We aimed to investigate the distribution of different types of drug outlets and their association with socio-economic factors. Methods: We mapped the location of drug outlets in 40 randomly selected geographic clusters, covering a population of 1.96 million people. Data including type of drug outlet, context, operating hours, chief pharmacist name and qualification, and business registration identification were collected from mandatory public signage. We describe the density of drug outlets and levels of staff qualifications in relation to population density, urban vs rural areas, and poverty indices. Findings: We characterised 1972 drug outlets. In the study area, there was an average of 102 outlets/per 100,000 population, compared to the global average of 25. Predictably, population density was correlated with the density of drug outlets. We found that drug outlets were less accessible in rural vs urban areas, and for the poor. Furthermore, for these populations, degree-qualified pharmacists were less accessible and public signage frequently lacked mandatory registration information. Interpretation: Drug outlets appear over-supplied in Vietnam compared to other countries. Unregistered outlets and outlets without degree-qualified pharmacists are prevalent, especially in poor and rural areas, posing a risk for inappropriate supply of antimicrobials, which may contribute to AMR, and raises questions of equitable healthcare access. Funding: This study was funded by a grant from the Australian Department of Foreign Affairs and Trade.

Inappropriate supply of antibiotics for common viral infections by community pharmacies in Vietnam: A standardised patient survey.

Background: This study aimed to evaluate the appropriateness of antibiotic dispensing of private pharmacies in Vietnam. Methods: Standardised patient surveys were conducted in randomly selected community pharmacies across 40 districts in Vietnam. Four clinical scenarios were represented by patient actors: (a) an adult requesting treatment for a sibling with a viral upper respiratory tract infection (URTI), (b) a parent requesting treatment for a child with acute diarrhoea, (c) an adult making a direct antibiotic request, and (d) an adult presenting with an antibiotic prescription. We calculated the proportion of interactions that resulted in inappropriate supply of antibiotics and patient advice. Predictors of inappropriate antibiotic supply were assessed. Findings: Patient actors attended 949 pharmacies, resulting in 1266 clinical interactions. Antibiotics were inappropriately supplied to 92% (291/316) of adults requesting treatment for URTI symptoms, 43% (135/316) for children with acute diarrhoea symptoms and to 84% (267/317) of direct request for antibiotics. Only 49% of pharmacies advised patients regarding their antibiotic use. Female actors were more likely to be given antibiotics than male actors for URTI (aOR 2·71, 1·12-6·60) but not for diarrhoeal disease. Pharmacies in northern Vietnam were more likely than those in southern Vietnam to supply antibiotics without a prescription: for adult URTI (aOR=5·8, 95% CI: 2·2-14·9) and childhood diarrhoea (aOR=3·5, 95% CI: 2·0-6·0) symptoms, but less likely to dispense for direct antibiotics request. Interpretation: Inappropriate antibiotic supply was common in Vietnamese private pharmacies. Multifaceted measures are urgently needed to achieve WHO's global action plan for the optimal use of antimicrobials. Funding: This study was funded by a grant from the Australian Department of Foreign Affairs and Trade.

Factors Related to Antibiotic Supply without a Prescription for Common Infections: A Cross-Sectional National Survey in Sri Lanka.

Inappropriate antibiotic use is a problem in Sri Lanka. We investigated pharmacy staff's attitudes towards antibiotic supply for common infections in Sri Lanka. A self-reported cross-sectional survey was conducted among a random sample (n = 369) of pharmacies. We assessed staff's beliefs and attitudes to antibiotic supplying for common infections (common cold and cough, sore throat, diarrhoea, wound and urinary tract infections (UTI)). Pharmacists (n = 210; 79%) and pharmacy assistants (n = 55: 21%) responded. About 30% (80/265) had supplied antibiotics without a prescription for common infections, including common cold (15.8%), sore throat (13.6%) and diarrhoea (10.2%). Overall, pharmacists were less likely to supply than non-pharmacists. Pharmacy staff with more positive beliefs about their professional competency to supply and monitor antibiotic use were more likely to supply antibiotics without a prescription for common cold (Adj.OR = 1.08; 95% CI: 1.01-1.15; p = 0.032), wound infections (Adj. OR = 1.06; 95% CI: 1.00-1.13; p = 0.059), and UTI (Adj.OR = 1.07; 95% CI: 0.99-1.15; p = 0.097). Pharmacy staff who believed in the effectiveness of antibiotics against common infections were more likely to supply antibiotics for common infections. Supply of antibiotics without a prescription was associated with staff's beliefs about antibiotics' effectiveness and their professional competency. Our findings could be used to strengthen regulatory strategies to improve practice.

Self-medication Behavior with antibiotics: a national cross-sectional survey in Sri Lanka.

BACKGROUND: Antibiotic self-medication is common in low- and middle-income countries. This study aimed to evaluate the Sri Lankan public's knowledge about and attitudes toward antibiotic use and self-medication, and factors associated with self-medication. METHODS: A national cross-sectional, interviewer-administered, survey of a random household sample (N = 1100) was conducted. Factor analysis of the attitudinal items was conducted to investigate the factors associated with antibiotic self-medication. RESULTS: A response rate of ninety-one percent (n = 998) responded. Knowledge about antibiotics was poor (mean = 12.5; SD = 3.5; (scale 0-27)). Half had previously used an antibiotic once in the past three months. About 11% (108/998) had self-medicated the last time they took antibiotics; mostly obtained from a pharmacy (82%; 89/108). Three attitudinal factors were obtained, explaining 56.1% of the variance. Respondents were less likely to self-medicate if they did not support ease of access to antibiotics from pharmacies (p< 0.001) and situational use of antibiotics (p= 0.001); supported appropriate use of antibiotics (p= 0.003); and had greater knowledge about prescription requirements for antibiotics (p= 0.004). CONCLUSION: There is limited knowledge about, and a high rate of self-medication with antibiotics.Factors contributing to self-medication could be addressed with appropriate public education campaigns, and policy changes.

Standardised patient study to assess tuberculosis case detection within the private pharmacy sector in Vietnam.

BACKGROUND: Of the estimated 10 million people affected by (TB) each year, one-third are never diagnosed. Delayed case detection within the private healthcare sector has been identified as a particular problem in some settings, leading to considerable morbidity, mortality and community transmission. Using unannounced standardised patient (SP) visits to the pharmacies, we aimed to evaluate the performance of private pharmacies in the detection and treatment of TB. METHODS: A cross-sectional study was undertaken at randomly selected private pharmacies within 40 districts of Vietnam. Trained actors implemented two standardised clinical scenarios of presumptive TB and presumptive multidrug-resistant TB (MDR-TB). Outcomes were the proportion of SPs referred for medical assessment and the proportion inappropriately receiving broad-spectrum antibiotics. Logistic regression evaluated predictors of SPs' referral. RESULTS: In total, 638 SP encounters were conducted, of which only 155 (24.3%) were referred for medical assessment; 511 (80·1%) were inappropriately offered antibiotics. A higher proportion of SPs were referred without having been given antibiotics if they had presumptive MDR-TB (68/320, 21.3%) versus presumptive TB (17/318, 5.3%; adjusted OR=4.8, 95% CI 2.9 to 7.8). Pharmacies offered antibiotics without a prescription to 89.9% of SPs with presumptive TB and 70.3% with presumptive MDR-TB, with no clear follow-up plan. CONCLUSIONS: Few SPs with presumptive TB were appropriately referred for medical assessment by private pharmacies. Interventions to improve appropriate TB referral within the private pharmacy sector are urgently required to reduce the number of undiagnosed TB cases in Vietnam and similar high-prevalence settings.

Antibiotic dispensing practice in community pharmacies: A simulated client study.

BACKGROUND: Dispensing antibiotics without a prescription, although forbidden by Sri Lankan law since 1986, is a common practice throughout the country. This study attempted to quantify this practice for the first time. OBJECTIVES: To evaluate the response of community pharmacy staff to an antibiotic product request without a prescription and to explore possible factors influencing such practice. METHODS: A cross-sectional simulated client study was conducted from Jan to Sept 2017. A total of 242 community pharmacies were visited by trained simulated clients (SCs) and they requested for one of four antibiotics (erythromycin tablets, amoxicillin syrup, metronidazole tablets, or ciprofloxacin tablets) without a prescription. Data on the interaction between the pharmacy staff and SC was recorded using a data collection sheet immediately after each visit. RESULTS: Nearly 50% of pharmacies had a pharmacist on duty during the visit. Attending pharmacy staff asked for a prescription for the requested antibiotic in 47% of the instances. Only 16 (7%) pharmacy staff recommended the SC to see a doctor. Overall, 61% of pharmacies dispensed antibiotics without a prescription. The highest dispensed antibiotic was ciprofloxacin (44/63 requests; 70%) and the least was amoxicillin (32/62; 52%). Patient history was obtained in only a few instances and none of the pharmacies dispensed alternative over the counter medicines. The availability of a pharmacist reduced the risk of dispensing an antibiotic without a prescription (Adj. OR = 0.54, 95% CI: 0.30-0.95; P = 0.033), however, it did not have any impact on patient history taking. CONCLUSIONS: Dispensing antibiotics without a prescription is a common practice in Sri Lankan community pharmacies. In most instances, pharmacy staff neither inquired about patient history nor requested the patient to obtain the advice of a doctor. Presence of a pharmacist may reduce dispensing antibiotics without prescription, but may not have an effect on interactions with clients requesting antibiotics.

Community pharmacy staff's response to symptoms of common infections: a pseudo-patient study.

Background: Inappropriate over-the-counter supply of antibiotics in pharmacies for common infections is recognised as a source of antibiotic misuse that can worsen the global burden of antibiotic resistance. Objectives: To assess responses of community pharmacy staff to pseudo-patients presenting with symptoms of common infections and factors associated with such behaviour. Methods: A cross-sectional pseudo-patient study was conducted from Jan-Sept 2017 among 242 community pharmacies in Sri Lanka. Each pharmacy was visited by one trained pseudo-patient who pretended to have a relative with clinical symptoms of one of four randomly selected clinical scenarios of common infections (three viral infections: acute sore throat, common cold, acute diarrhoea) and a bacterial uncomplicated urinary tract infection. Pseudo-patients requested an unspecified medicine for their condition. Interactions between the attending pharmacy staff and the pseudo-patients were audio recorded (with prior permission). Interaction data were also entered into a data collection form immediately after each visit. Results: In 41% (99/242) of the interactions, an antibiotic was supplied illegally without a prescription. Of these, 66% (n = 65) were inappropriately given for the viral infections. Antibiotics were provided for 55% of the urinary tract infections, 50% of the acute diarrhoea, 42% of the sore throat and 15% of the common cold cases. Patient history was obtained in less than a quarter of the interactions. In 18% (44/242) of the interactions staff recommended the pseudo-patient to visit a physician, however, in 25% (11/44) of these interactions an antibiotic was still dispensed. Pharmacy staff advised the pseudo-patient on how to take (in 60% of the interactions where an antibiotic was supplied), when to take (47%) and when to stop (22%) the antibiotics supplied. Availability of a pharmacist reduced the likelihood of unlawful antibiotic supply (OR = 0.53, 95% CI: 0.31-0.89; P = 0.016) but not appropriate practice. Conclusions: Illegal and inappropriate dispensing of antibiotics was evident in the participating community pharmacies. This may be a public health threat to Sri Lanka and beyond. Strategies to improve the appropriate dispensing practice of antibiotics among community pharmacies should be considered seriously.

A cross-sectional national survey of community pharmacy staff: Knowledge and antibiotic provision.

BACKGROUND: Pharmacists' knowledge about the clinical and legal aspects of antibiotic supply has an impact on appropriate dispensing practice. There are limited studies evaluating community pharmacists' knowledge of antibiotic dispensing in low and middle-income countries, including Sri Lanka. We aimed (i) to evaluate community pharmacy staff's self-reported knowledge about antibiotics and dispensing behaviour of antibiotics without a prescription, and (ii) to identify possible factors impacting their antibiotic dispensing behaviour. METHODS: A cross-sectional survey was conducted among a random sample (n = 369) of community pharmacies across all nine provinces in Sri Lanka using a self-administered questionnaire on their antibiotic knowledge and dispensing practice. Data were analysed using descriptive and inferential statistics including; t-test, one-way ANOVA or chi-square test, and binary and multiple logistic regression. RESULTS: A total of 265 pharmacy staff (210 (79%) pharmacists and 55 (21%) assistants) responded. Overall mean antibiotic knowledge score was 26.1 (SD 3.9; range 1-33, max possible score 34). The overall mean knowledge score t(263) = 2.41, p = 0.017, specific knowledge about antibiotic resistance (ABR) t(262) = 4.98, p = 0.021 and legal aspects of antibiotic dispensing χ2(1, N = 265) = 8.55, p = 0.003) were significantly higher among pharmacists than assistants. One in every three pharmacy staff reported that they dispensed antibiotics without a prescription on patient request; however the proportion was close to half when the patient was known to them. About 30% of the staff reported to have supplied antibiotics for minor infections in the week prior to the survey. However, there was no significant difference in the supply between pharmacists and assistants except for acute sore throat (12% vs 23%, respectively; p = 0.040). Those pharmacists with higher ABR knowledge were less likely to give out antibiotics without a prescription for viral infections in adults (Adj. OR = 0.73, 95% CI: 0.55-0.96; p = 0.027) and children (Adj. OR = 0.55, 95% CI: 0.38-0.80; p = 0.002). Awareness of legal aspects of antibiotic supply reduced overall dispensing (Adj. OR = 0.47, 95% CI: 0.30-0.75; p = 0.001), and specifically for bacterial infections in adults (Adj. OR = 0.45, 95% CI: 0.20-0.99; p = 0.047). Knowledge about antibiotic use and misuse reduced the likelihood of illegal dispensing for common cold (Adj. OR = 0.75, 95% CI: 0.60-0.94; p = 0.011) and acute diarrhoea (Adj. OR = 0.76, 95% CI: 0.58-0.99; p = 0.048). CONCLUSION: Despite the law prohibiting provision, antibiotic dispensing without a prescription continues in community pharmacies in Sri Lanka. Appropriate antibiotic dispensing was associated with high levels of pharmacists' legal and clinical knowledge about antibiotics. Strategies to change the current practice are urgently needed.

Activated charcoal significantly reduces the amount of colchicine released from Gloriosa superba in simulated gastric and intestinal media.

BACKGROUND: Poisoning with Gloriosa superba, a plant containing colchicine, is common in Sri Lanka. OBJECTIVES: This study was to estimate release of colchicine from 5 g of different parts of Gloriosa superba in simulated gastric and intestinal media, and examine the binding efficacy of activated charcoal (AC) to colchicine within this model. METHODS: A USP dissolution apparatus-II was used to prepare samples for analysis of colchicine using HPLC. RESULTS: Cumulative colchicine release from tuber in gastric media at 120 minutes was significantly higher (2883 µg/g) than in intestinal media (1015 µg/g) (p < .001). Mean ± SD cumulative colchicine concentration over 2 hours from tuber, leaves and trunk in gastric medium was 2883.15 ± 1295.63, 578.25 ± 366.26 and 345.60 ± 200.08 µg/g respectively and the release in intestinal media was 1014.75 ± 268.16, 347.40 ± 262.61 and 251.55 ± 285.72 µg/g respectively. Introduction of 50 g of AC into both media made colchicine undetectable (<0.1 µg/ml). CONCLUSIONS: The tuber released the highest quantity of colchicine. The colchicine release and elapse time to achieve saturated, equilibrium dissolution mainly depends on physicochemical properties of plant part. Significant in vitro binding of colchicine to AC suggests that AC has a role in decontamination of patients presenting to hospital after ingestion of Gloriosa superba.

Acute intentional self-poisoning with a herbicide product containing fenoxaprop-P-ethyl, ethoxysulfuron, and isoxadifen ethyl: a prospective observational study.

BACKGROUND: Herbicides are commonly ingested for self-harm, but relatively little has been published on poisoning with herbicides other than paraquat and glyphosate. We report here a case series of patients with acute exposure to a combination herbicide (brand name Tiller Gold or Whip Super) containing the selective phenoxy herbicide compounds fenoxaprop-P-ethyl and ethoxysulfuron and a safener isoxadifen ethyl. METHOD: Clinical data on all patients presenting with Tiller Gold or Whip Super poisoning to two General Hospitals in Sri Lanka from 2002-2008 were collected prospectively until discharge. RESULTS: Eighty-six patients with a history of Tiller Gold or Whip Super ingestion were included. The main clinical features were an epigastric burning sensation and vomiting; however, most of those who vomited had received gastric lavage or forced emesis. Eight patients had a reduced level of consciousness on admission (Glasgow coma scale 9-14) that resolved without intervention over several hours. Only symptomatic and supportive care was required. The median hospital stay was 1 day (IQR: 1-2) and the case fatality was zero (95% confidence interval: 0-4.2%). This low case fatality compared favorably with the case fatality of other common herbicides in our cohort: paraquat >40%, propanil >10%, 4-chloro-2-methylphenoxyacetic acid > 5%, and glyphosate >2%. CONCLUSION: This combination herbicide product appears to be safe in patients with acute self-poisoning, particularly in comparison with other herbicides, and causing few clinical features.

Acute human self-poisoning with imidacloprid compound: a neonicotinoid insecticide.

BACKGROUND: Deliberate self-poisoning with older pesticides such as organophosphorus compounds are commonly fatal and a serious public health problem in the developing world. The clinical consequences of self-poisoning with newer pesticides are not well described. Such information may help to improve clinical management and inform pesticide regulators of their relative toxicity. This study reports the clinical outcomes and toxicokinetics of the neonicotinoid insecticide imidacloprid following acute self-poisoning in humans. METHODOLOGY/PRINCIPAL FINDINGS: Demographic and clinical data were prospectively recorded in patients with imidacloprid exposure in three hospitals in Sri Lanka. Blood samples were collected when possible for quantification of imidacloprid concentration. There were 68 patients (61 self-ingestions and 7 dermal exposures) with exposure to imidacloprid. Of the self-poisoning patients, the median time to presentation was 4 hours (IQR 2.3-6.0) and median amount ingested was 15 mL (IQR 10-50 mL). Most patients only developed mild symptoms such as nausea, vomiting, headache and diarrhoea. One patient developed respiratory failure needing mechanical ventilation while another was admitted to intensive care due to prolonged sedation. There were no deaths. Median admission imidacloprid concentration was 10.58 ng/L; IQR: 3.84-15.58 ng/L, Range: 0.02-51.25 ng/L. Changes in the concentration of imidacloprid in serial blood samples were consistent with prolonged absorption and/or saturable elimination. CONCLUSIONS: Imidacloprid generally demonstrates low human lethality even in large ingestions. Respiratory failure and reduced level of consciousness were the most serious complications, but these were uncommon. Substitution of imidacloprid for organophosphorus compounds in areas where the incidence of self-poisoning is high may help reduce deaths from self-poisoning.