## 4 Discussion  
Enterococci belong to the normal bacterial microbiota of the gastrointestinal tract. Although they are characterized by low virulence, the development of bacteremia, endocarditis, and peritonitis are the consequence of decreased intestinal defense mechanisms [28; 35]. They have been of particular concern in recent years due to their ability to spread easily in hospitals among health workers and hospitalized patients and are included among the main microorganisms that cause nosocomial infections [36; 37; 38]. In the present study, similar percentages of 47.7% E. _facetulis_ (41 strains) and _E. facetium_ (41 strains) were isolated from the clinical samples. Bacteremia with enterococci is mainly nosocomial, with the community ones signaling the suspicion of endocarditis. In the U.S., three out of four nosocomial bacteremias per 10,000 hospitalizations are caused by enterococci and increase the risk of death [38]. In a recent retrospective study from China, the incidence of enterococcus in the blood infections (BSI) of hospitalized patients was four cases per 10,000 hospitalizations, with the main isolated pathogen being _E. facetium_ (74%) [39; 40]. Similar studies suggest that nosocomial BSI with enterococci is increasing and that overall mortality is quite high, ranging from 25% to 50% [41]. Many studies have reported that bacteremia caused by VRE strains leads to higher mortality rates (2.5-fold increase), compared to bacteremia caused by vancomycin-sensitive strains [42; 43]. In our study, 32.6% were isolated from hemocultures, with a frequency of 46.4% for _E. facetium_ and 39.2% for _E. facetalis_. More common are infections located in the urinary tract (38.4%) and soft tissue infections (22%). According to a similar study, the maximum number of isolates was obtained from urine (46.6%), followed by purulent secretions (19.4%) [44]. These data highlight the prevalence of enterococci in urinary tract infections (UTIs). Many studies have shown the association between biofilm production and urinary catheters in persistent infections [45; 46]. In these cases, UTI treatment involves the use of broad-spectrum antibiotics, which are the main cause of the spread of VRE strains. Another major problem associated with _Enterococcus_ spp. infections, along with the increased incidence rate, is the increased resistance to antimicrobial agents [47; 48]. Enterococci have intrinsic resistance to several categories of antibiotics, such as cephalosporins, sulfonamides, and low concentrations of aminoglycosides [28; 35]. In enterococcal infections, the success of treatment depends essentially on the ability to acquire new resistance markers through horizontal transfer mediated by plasmids or transposons and through genetic recombination or mutations. Antimicrobial resistance (AMR) is a health threat to millions of people worldwide. The COVID-19 pandemic has exposed the weaknesses of national health systems and the interconnection between countries and continents [28]. The pandemic years had a particular profile in terms of antibiotic resistance through the isolation of a small number of bacteria. In the present study, resistance to ampicillin and gentamicin HL was 7.3% vs. 30.1% for _E. faecalis_ and 80.5% vs. 41.1% for _E. ficeum_. According to EARS-Net data, at the European level, high-level resistance to aminoglycos (HLAR) in strains of _E. faecalis_ from invasive infections is increasing and was 29% in 2020. In 2020, Romania reported a resistance to gentamicin HL of 43.2%, up from 2019 [2; 36]. Enterococci also have a low susceptibility to many \(\beta\)-lactam agents due to their decreasing affinity for penicillins binding proteins that bind penicillin. However, there is typically synergy between aminoglycos and penicillins or glycopeptides against enterococci without the acquiring of high-level resistance to glycopeptides. Some enterococci have acquired genes conferring high-level resistance to aminoglycos, causing the loss of any synergistic effect between beta-lactams and aminoglycos [2].