Shortly after Vancomycin was introduced into the practice, it was well known for its nephrotoxicity. vancomycin itself is nephrotoxic as a result of the high usage when the exact mechanism how this occurs was not determined. risk factors have been identified associated with vancomycin-associated nephrotoxicity development, total daily dose more than 4 grams, trough levels more than 20 mgml, therapy more than six days, preexisting renal disease, obesity, concurrent use of other nephrotoxic agents, increasing the severity of illness and hypotensive episodes. vancomycin nephrotoxicity is reversible in most cases with discontinuation, but permanent kidney damage can occur. 21 Vancomycin-induced nephrotoxicity was 10–20 % and 30–40 % of patients following conventional and high doses of vancomycin treatment, respectively . its nephrotoxicity can be due to an increased production of oxidative stress and reactive oxygen species. There are many risk factors that could potentiate or accelerate the vancomycin-induced renal toxicity to occur , ( most common risk factors are high trough vancomycin level (especially >20 mg/L) or doses (>4 g/day), concomitant treatment with nephrotoxic agents, prolonged therapy (even more than 7 days), and admittance to an intensive care unit (especially prolonged stay)). 22Upon searching scientific literature, there aren’t too many studies that compare between vancomycin and other B-lactams induced nephrotoxicity versus vancomycin alone induced nephrotoxicity.According to retrospective studies comparing Vancomycin vs. Vancomycin/Piperacillin-Tazobactam-Associated Acute Kidney Injury results evaluated patients retrospectively, 24% taking vancomycin in combination with piperacillin-tazobactam developed AKI while 11% given vancomycin without piperacillin-tazobactam. After adjustment for age, sex, body mass index, concomitant nephrotoxic agents, and preexisting comorbid status as evaluated by Charlson comorbidity index. To conclude increased incidence of renal toxicity was Significantly noted with vancomycin and piperacillin-tazobactam compared to vancomycin. 23 Risk of AKI with Vancomycin piperacillin-tazobactam had an increase as compared to vancomycin ± ?-lactam. So, there is a need that practitioners be vigilant when prescribing this combination. Overall, there was an association with the development of AKI with vancomycin + piperacillin-tazobactam compared with vancomycin ± ?-lactam. The association remained significant when abstracts were removed and when low-quality studies were removed.The association for the development of AKI with vancomycin + piperacillin-tazobactam compared with vancomycin alone was significant, although the association did not remain significant for the vancomycin + ?-lactam subgroup. 24A retrospective cohort study that gives a direct comparison between the Risk of AKI in critically ill and non-critically ill patients treated with Vancomycin Piperacillin -Tazobactam combination is highly recommended. although our study is a short-term period.