Exposure to pH 1 or 2 buffers or acidic gastric contents resulted in the killing of vancomycin-resistant Enterococcus sp., Klebsiella pneumoniae, Staphylococcus aureus, and Candida glabrata but not Clostridium difficile spores. Nitrite enhanced killing under acidic conditions, but significant killing of C. difficile spores required nitrite concentrations above usual physiological levels.Gastric acid may provide an important host defense by killing ingested pathogens (5). For example, normal gastric acidity kills more than 99.9% of several gram-negative bacilli within 30 min (9), and vegetative cells of Clostridium difficile are killed within 5 to 30 min upon exposure to pH 2 to 3 buffers (17). Many studies have demonstrated an association between medications that inhibit production of stomach acid (e.g., proton pump inhibitors and H 2 blockers) and nosocomial pathogens, including C. difficile, Candida albicans, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), and extended-spectrum--lactamase-producing enterobacteriaceae (1-3, 12, 16). These findings suggest that gastric acid may provide an important defense against these organisms; however, relatively little information is available regarding the ability of acidic conditions to kill nosocomial pathogens. In addition, it has recently been demonstrated that salivary nitrites that are converted to reactive nitrogen compounds under acidic conditions may enhance the killing of pathogens in the stomach (6-8). Acidified nitrite is a sporicidal disinfectant that efficiently kills C. difficile spores (18), but it is not known whether the concentrations in the stomach provide sporicidal activity. Therefore, we examined the ability of acidic buffers, with or without the addition of physiological concentrations of nitrite, to kill C. difficile spores and several strains of Klebsiella pneumoniae, VRE, MRSA, and Candida glabrata. We also examined the killing of the pathogens by acidic gastric contents obtained from patients not receiving acid-suppressive medications.For K. pneumoniae, VRE, and MRSA, five isolates from distinct pulsed-field gel electrophoresis groups were studied. The K. pneumoniae isolates were bloodstream isolates that produce extended-spectrum -lactamases (11). The VRE isolates were clinical E. faecium isolates from Cleveland, and the MRSA isolates were cultured from the stool of patients (4, 10). For C. glabrata, three isolates were studied and have been described previously (15). For C. difficile, three isolates were studied, including one clinical isolate from Cleveland and ATTC strains 9689 and 43593.Initial experiments were performed to examine the effect of exposure to acid; C. difficile spores were not included in this analysis because preliminary experiments indicated that pH 1 buffer did not kill the spores. The pathogens were grown overnight in brain heart infusion broth and washed three times in phosphate-buffered saline (PBS). A final concentration of 10 9 CFU/ml of the pathogens was suspended i...