UNLABELLED: Rapid and accurate identification of cultured molds is important to determine clinical significance and therapeutic decision-making. Conventional mold identification uses phenotypic macroscopic and microscopic characterization
however, this can take days or weeks for colony maturity and definitive microscopic structure formation, be limited to genus-level identification, and be misidentified due to morphologic mimics or similarities between closely related species. Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) revolutionized bacterial and yeast identification but remains uncommon for molds in part because of limited reference libraries. Here, a retrospective 5-year review at a large teaching hospital found that 88.6% of identified molds were in the Bruker Filamentous Fungi Library 3.0 and 91.5% in the VITEK Knowledge Base Library 3.2.0. A prospective evaluation was also performed on early growth from 205 consecutive, working clinical isolates. Each mold was processed using the VITEK chemical extraction method and modified NIH chemical plus bead-beating extraction method
both extractions were tested on both systems. When compared to conventional identification, more molds were identified using VITEK extractions over NIH extractions using the VITEK (65 and 59%) and Bruker (56 and 54%) systems, respectively, using the ≥1.5 log Bruker threshold. VITEK MS identified more molds, regardless of the extraction method. Isolates without consensus agreement ( IMPORTANCE: Mold identification using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) remains uncommon in clinical laboratories. Contributing concerns include limited genus/species spectra in the MALDI-TOF MS libraries, varying success rates in the literature regarding extraction methods and instrumentation, and the lack of practical performance evaluations using early mold colony growth, which would be used in a clinical mycology laboratory. This study used multiple approaches to improve our understanding of the clinical utility and performance of MALDI-TOF MS mold identification.