Objective <p>Placement of a GT after a ventriculoperitoneal shunt (VPS) is a known risk factor for VPS infection, but the timing and sequence between procedures is poorly delineated in the neonatal population. The aims of this study were (1) determine the rate of meningitis in infants with a VPS and GT compared to VPS, (2) identify meningitis pathogens, and (3)&#xa0;define the optimal sequence and timing between placement of VPS and GT to minimize device-associated infections.</p> Study design <p>This retrospective cohort study includes infants with VPS placement from two level IV NICUs from January 1, 2010 to August 31, 2022. Infants with VPS placed for all causes of hydrocephalus were included. We compared infants with and without GTs, defined as gastrostomy or gastrojejunostomy tubes. The outcome of VPS-associated meningitis was defined by positive cerebral spinal fluid culture after VPS placement.</p> Result <p>The incidence of VPS-associated meningitis in VPS and GT infants was 10.6% versus 3.4% in VPS only infants (<i>p</i> = 0.013, OR 0.3, 95% CI 0.12, 0.86). Pseudomonas species were the most common etiology of meningitis in VPS and GT infants while enterococcus was the most the common pathogen in VPS only cohort. In the subgroup of infants with VPS and GT, there was no statistical difference in rates of VPS-associated meningitis in those with VPS placed first and those with GT placed first.</p> Conclusion <p>In infants with hydrocephalus requiring VPS, GT placement was a risk factor for VPS-associated meningitis and may impact pathogenic cause of meningitis. Larger, multicenter cohorts may be helpful to determine optimal sequence and timing of VPS and GT placement in these high-risk infants.</p>