RANDOMIZED TRIAL OF CAREGIVER TEXT-MESSAGE NUDGES IMPROVING ANTIBIOTIC STEWARDSHIP IN PEDIATRIC RESPIRATORY INFECTIONS

Background: Inappropriate antibiotic use for pediatric respiratory infections remains a persistent challenge, contributing to antimicrobial resistance and unnecessary healthcare utilization. Caregivers often initiate antibiotics without medical indication due to uncertainty about illness progression. Low-cost SMS reminders may offer a practical tool to strengthen outpatient antibiotic stewardship. Objective: To evaluate whether brief, behaviorally informed SMS reminders sent to caregivers reduce inappropriate antibiotic use and related unplanned revisits compared with standard discharge advice alone. Methods: A randomized controlled trial was conducted in outpatient pediatric clinics across South Punjab, enrolling 382 caregiver–child pairs presenting with non-bacterial respiratory infections. Participants were randomized 1:1 to receive either routine discharge guidance alone or routine guidance plus SMS reminders over 72 hours. Primary outcome was inappropriate antibiotic use within 10 days. Secondary outcomes included unplanned revisits, caregiver understanding of symptom expectations, and confidence in home management. Data were collected through structured follow-up calls and analyzed using chi-square tests, t-tests, and adjusted logistic regression. Results: Inappropriate antibiotic use occurred in 12.1% of the SMS group compared with 27.6% of the control group. Unplanned revisits were lower in the SMS group (10.0%) than in controls (21.8%). Caregiver understanding of expected symptom duration and red-flag signs was substantially higher in the intervention arm. Mean caregiver confidence scores were also greater among SMS recipients. Adjusted regression showed significantly lower odds of inappropriate antibiotic use (OR 0.36; 95% CI: 0.21–0.61) and revisits (OR 0.40; 95% CI: 0.22–0.74) in the intervention group. Conclusion: Behaviorally designed SMS reminders effectively improved caregiver practices, reducing inappropriate antibiotic use and unnecessary revisits. This low-cost, scalable strategy offers a practical approach to strengthening outpatient antibiotic stewardship in resource-limited settings.