OBJECTIVE: To identify differences in management levels and costs between nursing home (NH) residents with and without Clostridium difficile associated diarrhea (CDAD). METHODS: Minnesota long-term care data from 1995-2001 were examined for residents with (ICD-9-CM code: 008.45) and without CDAD. NH residents are assigned to one of eleven management categories reflecting low to very high care needs, based on assessment of dependence in activities of daily living (ADL), need for skilled nursing and behavior. Reimbursement rates are set for each management category based on expected care needs. Dependence in ADL, need for skilled nursing, behavior and assigned management category were analyzed. Costs were estimated by applying Minnesota NH reimbursement rates, adjusted to national values to each management profile. Cost estimates (2002 US$) include room and board, nursing and ancillary staff care. RESULTS: CDAD was coded for 260 (0.1%) of the 220,123 NH residents analyzed. Age and gender were similar for both groups. Residents with CDAD had significantly more bowel incontinence (p=0.000), required more skilled nursing services (p=0.000) and were more dependent in walking (p=0.001), transferring (p=0.002), bed mobility (p=0.003), as well as in, albeit not statistically significant (p>0.5), dressing, bathing and eating. Residents without CDAD had significantly more (p=0.001) behavioral problems and were slightly more dependent (p>0.05) in grooming. Increased ADL dependency and need for skilled nursing resulted in residents with CDAD being assigned to higher management categories significantly (p=0.000) more often than those without CDAD. This increase in management results in an additional $2985 in care costs annually per NH resident with CDAD, on average. CONCLUSIONS: CDAD constitutes a physical burden to the resident and an economic burden to the long term care system in terms of direct care costs, as well as opportunity costs due to the need for increased skilled nursing services.