Resistance Dynamics in a Romanian Critical Care Unit: Four Years of ESKAPE Pathogen Surveillance

<i>Background and Objectives:</i> Antimicrobial resistance is one of the most significant threats to modern healthcare, especially in intensive care units where ESKAPE pathogens<i>-Enterococcus faecium</i>, <i>Staphylococcus aureus</i>, <i>Klebsiella pneumoniae</i>, <i>Acinetobacter baumannii</i>, <i>Pseudomonas aeruginosa</i>, and <i>Enterobacter</i> spp.-account for the majority of healthcare-associated infections. Romania is among the European countries with the highest rates of antimicrobial consumption and resistance. This study aimed to describe the epidemiological trends and antimicrobial resistance profiles of ESKAPE isolates over a four-year period (2021-2024) in a Romanian ICU (Intensive Care Unit). <i>Materials and Methods:</i> We conducted a retrospective observational study of all microbiological samples collected from adult ICU patients at the Clinical Emergency County Hospital of Sibiu between 2021 and 2024. Data were extracted from the electronic laboratory system and included patient demographics, specimen types, isolated microorganisms, and antimicrobial resistance classifications. Statistical analyses were performed using Python libraries, with significance set at <i>p</i> < 0.05. <i>Results:</i> A total of 801 infections were recorded, of which 562 (70.2%) involved ESKAPE pathogens. The predominant organisms identified were <i>Klebsiella pneumoniae</i> (42.8%) and <i>Acinetobacter baumannii</i> (36.0%), followed by <i>Pseudomonas aeruginosa</i> (11.2%). Nearly half of the isolates (47.3%) were multidrug-resistant, and 22.3% were extensively drug-resistant. Respiratory specimens, particularly tracheal aspirates, accounted for the majority of the isolates and exhibited the highest proportion of resistant phenotypes. A significant temporal increase in extensively drug-resistant isolates was observed over the study period (<i>p</i> < 0.05). <i>Conclusions:</i> ESKAPE pathogens remain the leading causes of ICU infections in Romania, with <i>Klebsiella pneumoniae</i> and <i>Acinetobacter baumannii</i> contributing significantly to the burden of multidrug- and extensively drug-resistant infections. Strengthening infection prevention strategies, optimizing antimicrobial stewardship, and implementing continuous microbiological surveillance are essential to mitigate the evolving resistance crisis in Romanian critical care settings.