ABSTRACT Background: Severe community-acquired pneumonia remains a major cause of morbidity and mortality worldwide, with a significant cause of death among children under 5 years old and adults over 70 years old. Every year, pneumonia causes millions of hospital admissions and hundreds of thousands of fatalities worldwide, with low- and middle-income nations bearing the brunt of the disease. Sub-Saharan Africa has a disproportionately high death rate due to a lack of access to early diagnosis, intensive care support, and appropriate antimicrobial therapy. Objective of the study: This study aimed to assess thetreatment outcomes and associated factors of unfavorable (in hospital death, complications, need for antibiotic revision) outcomes of severe community-acquired pneumonia patients at TGSH from December 10, 2025, to January 10, 2026. Methods: A Hospital-based cross-sectional study was conducted among 290 adult patients admitted to TGSH with diagnosis of SCAP from December 10, 2025, to January 10, 2026. The systematic random sampling technique was used to get the sample population. Data were collected from medical records using a structured checklist, including socio-demographic characteristics, clinical profiles, laboratory results, treatment modalities, and outcome-related information. The collected data were entered into the Statistical Package for the Social Sciences (SPSS version 27) for analysis after it was coded. Descriptive statistics were used to estimate the magnitude of unfavorable outcomes, while Bivariate and multivariate logistic regression models were used to identify the association between dependent and independent variables. Adjusted odds ratio with a 95% confidence interval was used to estimate the strength of association, and the level of statistical significance was declared at a p-value of less than 0. 05. Result:In this study, from 290 patients 30.7% experienced unfavorable outcomes (including 13.4% in-hospital mortality, need for antibiotic revision, and development of complications during hospitalization). The main factors associated with these unfavorable outcomes include an SPO2 level below 90% (AOR=2.83), HIV positivity (AOR=3.5), a high CURB-65 score (AOR=2.94), and bilateral/multifocal pneumonia (AOR=2.08). Conclusion: Low oxygen saturation, HIV infection, high CURB-65score and bilateral /multifocal/ pneumonia were independent factors for unfavorable outcome of SCAP treatment.