c Clostridium difficile (Peptoclostridium difficile) is a common health care-associated infection with a disproportionately high incidence in elderly patients. Disease symptoms range from mild diarrhea to life-threatening pseudomembranous colitis. Around 20% of patients may suffer recurrent disease, which often requires rehospitalization of patients. C. difficile was isolated from stool samples from a patient with two recurrent C. difficile infections. PCR ribotyping, whole-genome sequencing, and phenotypic assays were used to characterize these isolates. Genotypic and phenotypic screening of C. difficile isolates revealed multiple PCR ribotypes present and the emergence of rifamycin resistance during the infection cycle. Understanding both the clinical and bacterial factors that contribute to the course of recurrent infection could inform strategies to reduce recurrence. (This study has been registered at ClinicalTrials.gov under registration no. NCT01670149.) C lostridium difficile (Peptoclostridium difficile) is a common health care-associated infection with a disproportionately high incidence in elderly patients. Recurrent Clostridium difficile infection (CDI) is known to occur in approximately 20% of patients following withdrawal of treatment antibiotics (1); however, this may rise to 65% if a patient has a history of CDI (2). Recurring CDI not only causes distress to patients but is also a substantial burden on the health care system due to the increased cost (3) associated with possible prolonged stay or readmission of a patient to the hospital and the readministration of diagnostic tests and antibiotics (4). Collaborations between clinicians and researchers are contributing to knowledge of how both the host and bacterium are affecting recurrent disease in order to reduce recurrence rates through personalized patient care regimens (5).In this study, multiple stool samples from a patient enrolled in a clinical trial were collected and C. difficile was isolated. The strains isolated from these samples were then phenotypically and genotypically characterized to deduce if changes in the C. difficile strain genotype and phenotype could have contributed to recurrent infection.Case. A male participant (01008), aged 85 years, had a history of chronic kidney disease and was on multiple long-term medications, including bumetanide, candesartan, digoxin, simvastatin, doxazosin, ferrous fumarate, and prednisolone. Three months prior to trial enrollment the participant received cefuroxime and gentamicin for a urinary tract infection. One month prior to trial enrollment he was admitted to the hospital, where he received clindamycin (both orally and intravenously) for an infected leg ulcer.In June 2013, after being readmitted to the hospital, he was diagnosed with CDI (Table 1, sample A), treated with metronidazole (MET), and discharged. He was diagnosed again with CDI in July (Table 1, sample B) and was treated again with MET.In July 2013, within 5 days of cessation of successful treatment of CDI with MET (defined as ce...