I have just installed this on my own forum in an effort to reduce spam as well. Local tests showed it worked well, and there should also be a lot of flexibility to create sections of the forum that don't require any approval, sections that require approval all the time, and sections where approval is needed only for the first posts.
If it's not obvious, it's the number of posts approved that count, not the number of posts created. So users can create as many posts/discussions as they want, all of them will be hold for approval. Only posts created after getting the number of approvals required won't be held for approval.
The extension appears to play well with other extensions that use approval. You might end up with multiple flags on a single post if multiple extensions flagged it for different reason, but it seems to only count +1 upon approval however many flags it got, so this shouldn't mess up with the counters.
If I auto-approve some users upon the initial installation, I'll need to write a command with some options. On my own forum I have a good number of existing users who never posted and I do want those users to be subjected to the first post approval. I could change the logic to be based on the number of existing public posts, but this might not play well with the ability to have tags under which no approval is required.