b Matrix-assisted laser desorption ionization-time of flight mass spectrometry for identification of Nocardia species remains challenging. By identifying 83.1% (64 of 77) and 80% (8 of 10) to the species and complex levels, respectively, and 94.3% (82 of 87) to the genus level, we show that an approach using routine sample preparation, an up-to-date commercial database minimally augmented with custom spectra, and testing at an early stage of growth is promising. N ocardia species are aerobic actinomycetes belonging to the family Corynebacteriaceae. They are Gram-positive, weakly acid-fast environmental saprophytes with diverse colony morphologies and are the most commonly isolated aerobic actinomycete human pathogens (1). Nocardia infections generally result either from trauma-related introduction of the organism or from inhalation, particularly in immunocompromised patients. Pulmonary nocardiosis is characterized by pneumonia and can progress to a cavitary disease that may resemble tuberculosis. Disseminated disease, central nervous system involvement, and indolent pulmonary disease with cavities or contiguous spread are among the indicators used to test for Nocardia species (1, 2).Identification of Nocardia species is often performed by 16S rRNA gene sequencing (1, 3, 4), but matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS)-based identification has the potential to be a rapid and inexpensive alternative (5). Unfortunately, routine MALDI-TOF MS for identification of Nocardia species has proven difficult (6-8). Previous studies have stressed the need for enhanced sample preparation methods and/or considerably augmented reference spectrum databases to sufficiently identify Nocardia spp. (6,8). In this study, we demonstrated that the age of Nocardia cultures plays an important role in the success of MALDI-TOF MS identification. In addition, we showed that additional extraction steps beyond those recommended by the manufacturer are not required and that relatively modest augmentation of the current database is sufficient for the identification of routinely encountered Nocardia spp. By optimizing testing conditions using these approaches, we were able to improve the performance of MALDI-TOF MS for identification of Nocardia species.Clinical isolates (n ϭ 79) and type strains (n ϭ 8) of Nocardia species, selected on the basis of the frequency and diversity of isolates identified at ARUP Laboratories, were retrospectively tested by MALDI-TOF MS (Bruker Daltonics). These 87 isolates represented 25 unique Nocardia species identified to the species (n ϭ 77) or complex (n ϭ 10) level by partial 16S rRNA gene sequencing (Table 1). Reference spectra were created from the following additional 13 isolates identified to the species level by sequencing multiple genes (16S rRNA gene, hsp65, and secA1) (3, 9, 10): N. abscessus, N. araoensis, N. asiatica, N. asteroides, N. beijingensis, N. blacklockiae, N. brasiliensis, N. brevicatena, N. pseudobrasiliensis, N. puris, N. transvalensis, N...