This study investigated the epidemiological characteristics, resistance profiles, and virulence factors of 102 multidrug-resistant Pseudomonas aeruginosa strains isolated from intensive care units (ICUs). Notably, the extensively drug-resistant strain X13 was identified and selected for in-depth transcriptomic analysis to explore its resistance mechanisms. Among the clinical isolates, carbapenem resistance was the most prevalent phenotype, while amikacin resistance remained low. Molecular typing revealed high genetic diversity, with ST1639 being the most common. Most strains harbored exoT, suggesting a conserved virulence profile. Strain X13 was classified as ST244 and exhibited resistance to all tested antibiotics. Transcriptomic analysis revealed significant alterations in the expression of genes involved in cell wall synthesis, DNA repair, and stress responses, indicating their role in antibiotic resistance. The identification of differentially expressed genes and regulatory sRNAs (small RNAs) provides insight into the complex resistance mechanisms of X13. These findings contribute to a deeper understanding of multidrug resistance in P. aeruginosa and may inform future therapeutic strategies.