Background: More than 5.3 million under-five children were died and about 80% occurred in Sub-Saharan Africa and Southern Asia in 2018. More than 15% of globally and 17% of nationally of these deaths were contributed by severe community acquired pneumonia. Objective: To determine the incidence and predictors of poor outcomes of severe community acquired pneumonia among children 2-59 months of age hospitalized in Public Referral Hospitals of Amhara Region, North West Ethiopia, 2020. Methods: Institutional based, prospective cohort study from February to May /2020 was conducted. Systematic random sampling technique was used to select study participants. Data collectors and supervisors were trained for one day. Data were coded and entered into Epi-Data version 3.1 and exported to STATA version 14.1 cleaned and analyzed by using generalized linear model for binomial families. Variables in bi-variable analysis with p-values < 0.25 were included in multivariable analysis. Adjusted Relative Risk with 95% confidence interval and p-values < 0.05 were used to identify the association and strength of variables. Results: Of the intended sample of 600 children, 574 children with severe community acquired pneumonia were enrolled in to the study. This made the response rate of the study population 95.7%. Cumulative incidence of treatment failure, antibiotic change prolonged hospital stay and death was 15.7%, 10.6%, 19% 1.4% respectively and overall Cumulative incidence of poor outcome was 27.7%. The predictors were vaccination status (ARR 2.89, 95%CI: 2.14-3.91) and (ARR 2.22, 95% CI: 1.64-3.01) for not vaccinated and defaulters respectively compared to fully vaccinated. Impaired consciousness 3.58 folds, vomiting everything 3.27 times and chest in drawing 1.22 times increased the risk of poor outcomes. Presence of pallor (ARR 2.15, 95% CI: 1.76-2.61), presence of central cyanosis (ARR 3.36, 95% CI: 1.76-2.61), HIV positives (ARR 2.83, 95% CI: 2.44-3.29), severe wasting (ARR 1.58, 95% CI: 1.42-1.77) and living from a family of > 5 (ARR 1.3, 95% CI: 1.18-1.45). Conclusion: The cumulative incidence of the poor outcome was almost twenty eight percent (27.7%) of hospitalized children. So, measures should be taken to combat these adverse outcomes and farther study should be conducted. Key words: under-five children, severe community acquired pneumonia, poor outcomes, and cumulative incidence.