Leachate from municipal solid waste (MSW) incineration harbors a plethora of contaminants, including antibiotics and antibiotic resistance genes (ARGs). However, the understanding of such leachate is markedly scant in comparison to that of landfill leachate. In this study, the distribution and removal of 8 sulfonamides (SAs), 4 quinolones (FQs), and 4 macrolides (MLs) antibiotics in leachate from 14 MSW incineration plants in representative cities across different regions of China were investigated. In addition, potential factors affecting the contamination levels of antibiotics and ARGs in fresh leachate were evaluated. The results showed that the total concentration of target antibiotics in fresh leachate ranged from 4406.1 to 14,930.6 ng/L. Notably, the antibiotic distribution in leachate exhibited regional disparities, influenced by economic status, climatic conditions, and waste separation policies. The absolute abundance of total ARGs ranged from 1.3 × 10