Spatiotemporal dynamics and multiple driving factors of antimicrobial resistance in China during the COVID-19 pandemic (2019-2023): a provincial panel data analysis

Antimicrobial resistance (AMR) is a major and growing global health threat, with China experiencing a substantial burden. This study analyzed province-level patterns and One Health drivers of three critical resistant pathogens—MRSA, carbapenem-resistant Klebsiella pneumoniae (CRKP), and carbapenem-resistant Acinetobacter baumannii (CRAB)—across China from 2019 to 2023, spanning the COVID-19 pandemic. Significant geographic clustering was observed for CRKP and CRAB, while MRSA showed no clear spatial pattern. Distinct drivers were identified: MRSA was associated with livestock density and air pollution (PM2.5); CRKP with healthcare expenditure and pig farming; and CRAB with healthcare capacity indicators such as hospital beds and spending, alongside unexpected negative links with population aging and hospital stay length. COVID-19 had no direct statistical effect on resistance trends, suggesting mainly indirect influences. Overall, the findings reveal a spatially heterogeneous AMR landscape shaped by complex healthcare, agricultural, environmental, and socioeconomic factors, highlighting a “paradox of progress” where greater healthcare capacity coincides with higher levels of dangerous resistance. Effective control will require coordinated, region-specific One Health strategies integrating health, agriculture, and environmental policy.