BackgroundDeliberate 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 FindingsDemographic 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.ConclusionsImidacloprid 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.

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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 χ 2 (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.

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.