First most of my comments are directed towards the northern part of Italy. I have driven to the South but only along the East coast not in any of the cities. This part is just a general discussion. Part 2 will be more about rules of the road.
So, first I have driven a lot here over a period of many years of visits and now nearly two years of living here. We are making almost monthly trips from Belluno to Milan for our daughters orthodondist appointments and that is where Lusia's parents live most of the time. Driving here is not so different from driving in the US a few rules are different and some people tend to drive much faster on the Autostrada. Generally, though sometimes it may not seem that way no one wants to have an accident. And Italian drivers even or especially the ones driving fast pay a lot of attention to their driving. You don't see them eating a hamburger and fries while driving 150 k/hr.
Even though there is great public transportation driving a car is still the most efficient way to get around. It is possible to get around without one and if coming for a tour of Italy one sticks to the larger cities one can do well without one. And also if one is in a large city like Milan parking can be such a problem that public transportation becomes the best choice when possible. But once one gets out of the more dense areas moving about without a car can be a problem.
I will close this part by saying that if you are thinking of visiting Italy and want to get around as freely as possible don't hesitate to rent a car and drive.
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