Background and objectives: Neonicotinoids are a newer class of pesticides that are believed to cause predominantly mild toxicity in humans. This study aimed to describe the clinical features of neonicotinoid poisoning and identify predictors of severe toxicity. Materials and methods: This retrospective study included all patients with neonicotinoid poisoning admitted to a Tertiary Care Center in India over an 18-year period. Clinical and laboratory features were compared against outcomes to identify predictors of the need for intensive care admission. Results: Twenty-eight patients were included in the study of which 28.6% had severe disease requiring ICU admission. A higher respiratory rate, blood lactate level, SOFA, and qSOFA scores as well as a lower Glasgow coma score at presentation predicted ICU admission. First-generation compounds and imidacloprid consumption were associated with longer ICU stays and a longer duration of invasive ventilation. Conclusion: Neonicotinoid compounds can cause significant toxicity with oral ingestion. Imidacloprid and other first-generation compounds were associated with more severe toxicity requiring intensive care. Simple clinical parameters assessed at presentation can be used to predict severe disease and the need for ICU care. Larger, prospective studies are required to confirm these findings.