The Resistance Landscape of Uropathogens in a Romanian Tertiary Center: A 13-Month Single-Center Study with Focus on...

Urinary tract infections (UTIs) sit at a leading edge of the antimicrobial-resistance (AMR) crisis, and Romania ranks among the most affected European countries, yet large single-center series of urinary isolates with complete antibiograms remain scarce. We describe the full resistance landscape of urinary pathogens at a Romanian tertiary hospital, with particular attention to multidrug-resistant Klebsiella and to the often-overlooked urease-positive organisms. We analyzed all positive urine cultures processed over 13 consecutive months (February 2025-February 2026). The first isolate per patient was the primary unit of analysis (n = 2331); the full isolate-level dataset (n = 3348) was analyzed secondarily. Resistance phenotypes (putative ESBL, carbapenem resistance, MDR, VRE) were derived from per-agent susceptibility data following Magiorakos et al., and resistance rates were calculated only on tested isolates. Associations were tested with chi-square/Fisher tests and Benjamini-Hochberg correction. A total of 3348 isolates from 2331 unique patients were analyzed (median age 68 years; 55% male). Escherichia coli predominated (40.5%), followed by Enterococcus spp. (22.2%) and Klebsiella spp. (18.9%). Among the first isolates, 15.3% were MDR; 16.7% of E. coli, Klebsiella and Proteus showed a putative ESBL phenotype; and 3.9% of Enterobacterales were carbapenem-resistant. Resistance was concentrated in Klebsiella (36.2% MDR, 22.8% putative ESBL, 14.7% carbapenem-resistant; all higher than E. coli, p < 0.001) and in Pseudomonas spp. (48.1% carbapenem-resistant). E. coli retained excellent activity to nitrofurantoin (1.2%), fosfomycin (1.2%; tested in a subset) and ertapenem (0.1%) despite high trimethoprim-sulfamethoxazole (31.5%) and fluoroquinolone (24.3%) resistance. Urease-positive organisms formed a distinct subgroup with high trimethoprim-sulfamethoxazole resistance but preserved carbapenem activity. The urinary resistance burden was substantial but uneven, concentrated in Klebsiella and Pseudomonas. These findings support a stratified, locally guided empirical strategy and combined stewardship-infection control efforts.