Infection related to the placement of intracranial pressure (ICP) monitoring systems has been examined closely by practitioners. Review of the literature identifies many factors contributing to infection. In this two-year retrospective study of 52 patients who underwent ICP monitoring, 12 variables were studied: diagnosis, type of monitor, date and place of insertion, duration of monitoring, drainage, frequency of system change or irrigation and personnel involved, dressing changes, range of patient temperatures, culture results, concurrent infections and antibiotic therapy. Practices that minimized infection rates in our patient population are identified as well as implications for nursing practice and quality assurance measures for ICP monitoring.