Nitazoxanide (NTZ) is a redox-active nitrothiazolyl-salicylamide prodrug that kills Helicobacter pylori and also many anaerobic bacterial, protozoan, and helminthic species. Here we describe development and use of a spectrophotometric assay, based on nitroreduction of NTZ at 412 nm, to identify H. pylori enzymes responsible for its activation and mode of action. Three enzymes that reduce NTZ were identified: two related NADPH nitroreductases, which also mediate susceptibility to metronidazole (MTZ) (RdxA and FrxA), and pyruvate oxidoreductase (POR). Recombinant His-tagged RdxA, FrxA, and POR, overexpressed in nitroreductasedeficient Escherichia coli, each rapidly reduced NTZ, whereas only FrxA and to a lesser extent POR reduced nitrofuran substrates (furazolidone, nitrofurantoin, and nitrofurazone). POR exhibited no MTZ reductase activity either in extracts of H. pylori or following overexpression in E. coli; RdxA exhibited no nitrofuran reductase activity, and FrxA exhibited no MTZ reductase activity. Analysis of mutation to rifampin resistance (Rif r ) indicated that NTZ was not mutagenic and that nitrofurans were only weakly mutagenic. Alkaline gel DNA electrophoresis indicated that none of these prodrugs caused DNA breakage. In contrast, MTZ caused DNA damage and was strongly mutagenic. We conclude that POR, an essential enzyme, is responsible for most or all of the bactericidal effects of NTZ against H. pylori. While loss-of-function mutations in rdxA and frxA produce a Mtz r phenotype, they do not contribute much to the innate susceptibility of H. pylori to NTZ or nitrofurans.Prodrugs are particularly appealing as therapeutic agents because of their selective toxicity for microorganisms possessing specific activating enzymes (7). Metronidazole (MTZ) is a nitroimidazole prodrug that is often used in combination therapies against Helicobacter pylori, the microaerobic bacterium that causes gastritis and peptic ulcer disease and that is an early risk factor for gastric cancer (6,19,30). However, resistance to MTZ is very common and reduces the efficacy of MTZ-containing regimes (10). MTZ is also highly mutagenic, and hence its use may accelerate development of resistance to other clinically important antibiotics, such as clarithromycin (24,29). These considerations have stimulated interest in alternative redox-active prodrugs in either first-line or salvage (failed eradication) therapies, especially those against which resistance may be uncommon in H. pylori. Alternative prodrugs include the nitrofurans and nitrothiazoles, which exhibit antimicrobial activity against H. pylori and also against facultative anaerobes, anaerobic bacterial and protozoan species, and helminths (12,19,21,30,32,33). For these drugs, the spectrum of bioactivity and the mechanisms of activation are largely a function of the redox potential (EЈ 7 ) of the 5-nitro groups. For example, nitrofurans (nitrofurazone, nitrofurantoin, and furazolidone) display relatively high redox potentials (Ϫ250 to Ϫ270 mV) and are reductively activated by a...