THE EFFECT OF PAGODA LEAF EXTRACT (CLERODENDRUM PANICULATUM L) ON THE IL-10 LEVEL IN MAMMAE OF FEMALE RATS STRAIN (SPRAGUE DAWLEY) INDUCED WITH STAPHYLOCOCCUS AUREUS BACTERIA

Mastitis adalah masalah penyakit infeksi yang ditemukan pada ibu menyusui yang biasanya disebabkan oleh Staphylococcus aureus. Ketika bakteri Staphylococcus aureus masuk ke jaringan tubuh, kekebalan IL-10 akan aktif membantu mencegah selsel rusak. Sistem imun akan memburuk jika tidak ada penanganan. Sehingga dibutuhkan terapi komplementer seperti tanaman daun pagoda, kandungan dari tanaman daun pagoda terdiri dari tannins, alkaloids and flavonoids, di mana senyawa ini dapat meningkatkan sistem kekebalan tubuh. Jenis penelitian yang digunakan dalam penelitian ini adalah true experimental dengan rancangan pre dan posttest control design. Yang menggunakan tikus strain Sprague Dawley sebanyak 15 ekor yang dibagi dalam 3 kelompok yaitu kelompok kontrol negatif (aqua pro injections) sebanyak 5 ekor semuanya diberikan pakan standar, kelompok kontrol positif (Amoxicilin dengan dosis 9,6ml/250gramBB) sebanyak 5 ekor semuanya diberikan pakan standar, dan kelompok perlakuan (Amoxicilin 9,6ml/250gramBB ditambah dengan ekstrak daun pagoda (50ml/250gramBB) 5 ekor semuanya diberikan pakan standar. Semua kelompok diinduksisikan bakteri Staphylococcus aureus 0,2 ml/CFU. Pemeriksaan kadar IL-10 menggunakan metode R & D system Enzyme Linked Immonosorbent Assay (ELISA) Rat. Analisis data menggunakan uji ANOVA + post hoc, dengan nilai signifikan ρ ≤ 0, 05. Penelitian ini menunjukkan tidak ada perbedaan kadar sitokin IL-10, sebelum diinduksikan bakteri Staphylococcus aureus pada semua kelompok dengan nilai (ρ > 0,05).. Sedangkan setelah diinduksikan bakteri Staphylococcus aureus ± 24 jam semua kelompok mengalami penurunan kadar IL10 dengan nilai (ρ > 0,05). Setelah diberikan treatment diperoleh nilai ρ < 0,05) antara semua kelompok hal ini menunjukkan ada perbedaan kadar IL-10 setelah diberikan treatment antara semua kelompok. Pada kelompok kontrol negatif kadari IL-10 mengalami penurunan (rerata ± 10,4 pg/ml). Sedangkan peningkatan kadar IL-10 lebih besar pada kelompok perlakuan (rerata ± 58.4 pg/ml), dibandingkan pada kelompok positif (rerata ± 41.8 pg/ml ). Kesimpulan dalam penelitian ini adalah ekstrak daun pagoda (Clerodendrum Paniculatum L) memiliki pengaruh dalam meningkatkan kadar IL-10 sebagai anti-inflamasi. Ekstrak daun pagoda dapat dijadikan terapi komplementer.


INTRODUCTION
Breast inflammation or commonly referred to as mastitis is a disease that can be accompanied by infection or not accompanied by infection, while the type of bacteria that most often causes mastitis is the Staphylococcus aureus bacteria.This disease usually accompanies lactation, so it is also called lactational mastitis or commonly referred to as puerperal mastitis.This situation can be fatal if it is not handled properly.Mastitis generally occurs around 1 to 6 weeks post partum.The complications that will occur in mastitis are abscess in the breast.The incidence of mastitis according to the world health organization estimates that more than 4.1 million people are diagnosed with mastitis, and an estimated 3-20% of breastfeeding mothers can experience mastitis, 1 until 10 women (10%) who experienced mastitis in the first month after delivery.The signs and (IL-10) is an anti-inflammatory cytokine containing anti-inflammatory properties that can suppress the pro-inflammatory reaction Interleukin 10 has a role in limiting the immune response to pathogens, thus preventing damage to tissues and maintaining connective tissue homeostasis.Interleukin-10 levels as antiinflammatory cytokines will decrease if there is inflammation in the body (Couper N Kevin, et al 2008;Rayitno A, et al, 2014;Garcia YF, et al, 2011;Iyer Subramanian S, et al, 2012;Kumar Ashok, et al, 2000;AmirH. Lisa, et al, 2014) Inflammation when left without treatment will result in autoimmune or autoinflamation disorders, neurodegenerative diseases, or cancer.As for treatment so far which is still often used for inflammation is conventional treatment.Even though there are now many herbal plants that can be used as complementary therapies, one of them is

INTRODUCTION
Breast inflammation or commonly referred to as mastitis is a disease that can be accompanied by infection or not accompanied by infection, while the type of bacteria that most often causes mastitis is the Staphylococcus aureus bacteria.This disease usually accompanies lactation, so it is also called lactational mastitis or commonly referred to as puerperal mastitis.This situation can be fatal if it is not handled properly.Mastitis generally occurs around 1 to 6 weeks post partum.The complications that will occur in mastitis are abscess in the breast.The incidence of mastitis according to the world health organization estimates that more than 4.1 million people are diagnosed with mastitis, and an estimated 3-20% of breastfeeding mothers can experience mastitis, 1 until 10 women (10%) who experienced mastitis in the first month after delivery.The signs and symptoms of mastitis such as: Fever in the body, especially in the breast and experience inflammation of the breast accompanied by pain.The causes of mastitis include: starting from being infected by bacteria, scuffed nipples, improper breastfeeding techniques, infrequent breastfeeding frequency or short breastfeeding times, and overly fast weaning and attachment of babies to poor breasts, and babies who only sucking nipples (not including the areola) causing the nipple to squeeze between the gums or lips so that the milk flow is imperfect (WHO, 2000: Tri    halaman infrequent breastfeeding frequency or short breastfeeding times, and overly fast weaning and attachment of babies to poor breasts, and babies who only sucking nipples (not including the areola) causing the nipple to squeeze between the gums or lips so that the milk flow is imperfect (WHO, 2000: Tri Anasari, Sumarni. 2014: Amir H Lisa, et al, 2014: IDAI 2013;Anasary Tri Anasari, Sumarni. 2014 ;al, 2012;Dixon Michael J, et. al 2011: Khanal Vishnu, et al. 2015: Viduedo Silva, et al 2015: Baratawidjaja K, et al, 2014;Manzanillo Paolo, et al, 2015).Interleukin 10 (IL-10) including type II cytokines.This type of cytokine has an organizational form and binds to receptors that are similar in structure.Interleukin-10 (Joseph Jeenu, 2013).From the results of research conducted in India showed that pagoda leaves are also used as traditional medicine in Korea, for HIV, Syphilis, typhoid, Cancer, Jaundice, hypertension (M. Praveen, et al., 2012;Thakur, et al., 2013) From the various facts facts above which suggest that pagoda plants on the part of the pagoda roots and flowers contain active compounds that function as antiinflammatory agents which are so effective in curing various diseases such as like cancer, infections, boils.In certain areas the pagoda is strongly believed to be a complementary therapy in certain diseases.So that typhoid researchers were  Shrivastava, et al, 2007).From the phytochemical test results found that pagoda plants contain active compounds such as: flavonoids, tannins, alkaloids, phenolic acids, sterols, glycosides, phenolic acids, and glycosides (Joseph Jeenu, 2013).From the results of research conducted in India showed that pagoda leaves are also used as traditional medicine in Korea, for HIV, Syphilis, typhoid, Cancer, Jaundice, hypertension (M. Praveen, et al., 2012;Thakur, et al., 2013) From the various facts facts above which suggest that pagoda plants on the part of the pagoda roots and flowers contain halaman mastitis include: starting from being infected by bacteria, scuffed nipples, improper breastfeeding techniques, infrequent breastfeeding frequency or short breastfeeding times, and overly fast weaning and attachment of babies to poor breasts, and babies who only sucking nipples (not including the areola) causing the nipple to squeeze between the gums or lips so that the milk flow is imperfect (WHO, 2000: Tri Anasari, Sumarni. 2014: Amir H Lisa, et al, 2014: IDAI 2013;Anasary Tri Anasari, Sumarni. 2014 ;al, 2012;Dixon Michael J, et. al 2011: Khanal Vishnu, et al. 2015: Viduedo Silva, et al 2015: Baratawidjaja K, et al, 2014;Manzanillo Paolo, et al, 2015).Interleukin 10 (IL-10) including type II cytokines.This type of cytokine has an organizational form and binds to receptors that are similar in structure.Interleukin-10 that pagoda plants contain active compounds such as: flavonoids, tannins, alkaloids, phenolic acids, sterols, glycosides, phenolic acids, and glycosides (Joseph Jeenu, 2013).From the results of research conducted in India showed that pagoda leaves are also used as traditional medicine in Korea, for HIV, Syphilis, typhoid, Cancer, Jaundice, hypertension (M.Praveen, et al., 2012;Thakur, et al., 2013) From the various facts facts above which suggest that pagoda plants on the part of the pagoda roots and flowers contain active compounds that function as antiinflammatory agents which are so effective in curing various diseases such as like cancer, infections, boils.In certain areas the pagoda is strongly believed to be a complementary therapy in certain diseases.So that typhoid researchers were

Qanun Medika Vol. 3 No. 1 Januari 2019
Qanun Me giving pagoda leaves (Clerodendrum paniculatum L), to levels of IL10 cytokines.IL-10 levels are seen using the method Enzyme Linked Immunosorbent Assay (ELISA).Three levels of IL-10 were examined (3) time, blood collection first when rats have not been treated to assess whether IL-10 levels are normal or not, then taking blood the second time after the mouse was induced by Staphylococcus aureus bacteria, and taking blood last time when mice were given good in the negative, positive and treatment groups.The bivariate test uses a test one way anova to see differences in IL-10 levels in the negative control group before, during and after treatment, positive control before, during and after being given treatment, and treatment group before, during and after being given treatment and done.But if the data is not normally distributed then a test is carried out Kruskal-Wallis.other than that also done test repeted anova if the data is normally distributed to see differences in IL-10 levels in each group, namely the negative, positive, and treatment groups before, during and after being given treatment.The sample in this study were Sprague Dawley rats with a body weight of about 200-250 grams.With use of 15 rats strain Sprague Dawley divided into 3 groups: 5 negative control groups (aqua pro injections 1ml/gramBB) were all given standard feed, positive control group (Amoxicilin with 9.6ml / 250gramBB ) as many as 5 rats were all fed standard, and group feeding (Amoxicilin 9.6ml / 250gramBB plus pagoda leaf extract Accuracy of turbidity level Mc Farland measured by the Densi check tool.So that the dosage is injected into as many rats as possible 0,2 mlx10 8 ml/CFU.Bacterial induction is carried out by intramuscular technique in the breast part precisely in the lactiferous duct in rats in all groups (Negative, positive and treatment) after the induction of bacteria is then observed ±24 hours later to see an infection reaction in the rat breast area (There are signs of infection in the breast) The research data collection instrument was carried out by method Enzyme Linked Immunosorbent Assay (ELISA) to measure IL-10 levels.50ml/250gramBB) 5 rats were all given standard were all given standard feed.The instruments used in this study include materials, namely pagoda leaves from Belopa, Luwu, South Sulawesi, precisely in the people's house.And carried out extracted in the UNHAS Biopharmaca laboratory, previously the pagoda leaves were picked ± 5 kg of raw leaves, after that it is cleaned first, then sifted to obtain a smooth simplicia sample.After that the sample is ready to be extracted by maceration method, so that it is obtained ± 500 gram pagoda thick extract.The experimental animals used in this study were rats strain Sprague Dawley with weight 200-250 grams.And needed Aqua pro injection (for negative group), and amoxicillin 500 mg, (For positive groups), and the bacteria used are Staphylococcus aureus bacteria strain standard .To make a sample of bacteria by making a suspension in solution NaCl as much 10 ml mixed with Staphylococcus aureus bacteria colonies that golden yellow with turbidity level Mc Farland 2 x 10 8 CFU.Accuracy of turbidity level Mc Farland measured by the Densi check tool.So that the dosage is injected into as many rats as possible 0,2 mlx10 8 ml/CFU.Bacterial induction is carried out by intramuscular technique in the breast part precisely in the lactiferous duct in rats in all groups (Negative, positive and treatment) after the induction of bacteria is then observed ±24 hours later to see an infection reaction in the rat breast area (There are signs of infection in the breast) The research data collection instrument was carried out by method Enzyme Linked Immunosorbent Assay (ELISA) to measure IL-10 levels.220 ± 10 208 -231 *One way ANOVA.Significant value ρ 5 0.05.There were no differences in body weight in all groups, both in the negative, positive and treatment control groups (ρ = 0.56) The results of the statistical test of one way ANOVA before induced Staphylococcus aureus bacteria in each group obtained the value ρ = 0.58 greater than the value of α = 0.05.This means that there is no significant difference in the levels of IL-10 cytokines before induced Staphylococcus aureus bacteria between the negative, positive and treatment control groups.Whereas IL-10 levels after induced Staphylococcus aureus bacteria ± 24 hours in each group obtained values ρ = 0.68 greater than the value of α = 0.05.The results of the statistical test of one way ANOVA before induced Staphylococcus aureus bacteria in each group obtained the value ρ = 0.58 greater than the value of α = 0.05.This means that there is no significant difference in the levels of IL-10 cytokines before induced Staphylococcus aureus bacteria between the negative, positive and treatment control groups.Whereas IL-10 levels after induced Staphylococcus aureus bacteria ± 24 hours in each group obtained values ρ = 0.68 greater than the value of α = 0.05.
Picture 1: Trend of IL-10 levels in each group of female rats with Sprague Dawly strain before, after induced Staphylococcus.Aureus and after treatment..

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Description: IL-10 levels in each group before induced Staphylococcus aureus bacteria (homogeneous), and after induced Staphylococcus aureus bacteria all groups experienced a decrease in IL-10 levels.Whereas after giving the treatment the positive control group and the treatment increased, the group while the negative control group decreased.*Repetead ANOVA + post hoc in the treatment group before and after being given treatment obtained the value ρ = 0.64 greater than the value of α = 0.05.This shows no difference in levels of IL-10 cytokines before and after treatment in the treatment group.Whereas in the negative and positive control groups obtained a value of ρ <0.05, both before, after induction s. aureus ± 24 hours and after treatment.given antibiotics amoxilcillin at a dose of 9, 6 ml / 250grBB + pagoda leaf extract with a dose of 50 ml / grBB per day orally plus pagoda leaf extract 50 ml / g BB for 5 (five) days and showed inflammatory cells (± 34) Polymorphonuclear (PMN) around the connective tissue , the mammary gland and epithelial cells are reduced.

DISCUSSION
The results of the one way ANOVA test showed no significant difference in rat body weight for all groups, both in the negative, positive and treatment control groups.Whereas the results of the one way ANOVA test showed that there was no significant difference in levels of cytokine IL-10 before induction of Staphylococcus aureus bacteria, both in the negative, positive and treatment controls.This indicates that before inducing the Staphylococcus aureus bacteria the condition of mice in each group was not in a healthy condition.After the rats were ascertained in a healthy condition, it was continued by inducing Staphylococcus aureus bacteria (0.2 mlx108ml / CFU).All groups were induced by bacteria so that the rats were exposed to bacteria.In the negative control group, 1 ml / 200gram BB mice aqua pro injection was given.In this group, levels of IL-10 cytokines were decreased.This is due to an immune response in the body called pro inflammation.IL-10 cytokines are no longer able to suppress proinflammatory consequences, there is an inflammatory response or infection.This is in line with research conducted by John M. Leech who got interleukin-10 levels decreased after 24 hours after induced Staphylococcus aureus bacteria, so that mice will be exposed.Even up to 7 days the level of Interleukin 10 has decreased dramatically, if not given treatment such as antibiotics.(Jawetz, 2005: Ziegler Christina, 2011: Li Huimin, et al, 2017: jawetz, 2005: Ziegler Christina, 2011, John M. Leech, 2017: Manzanillo Paolo, et al, 2015: Ziegeler Christina, et al, 2011) (John M. Leech,2017: Manzanillo Paolo,et al, 2015: Ziegeler Christina,et al, 2011).
In the positive control group, rats were induced by Staphylococcus aureus bacteria (0.2 ml x 108 ml / CFU) and given Amoxicilin treatment with a dose of 9.6 mg / ml / 250 gBB mice for 5 days.The results showed that there were differences in levels of IL-10 cytokines before bacterial induction and after antibiotic administration.The result is clear that there are differences between groups before, during and after being given Amoxicilin treatment with a dose of 9.6mg / ml / 250gramBB (S Jahanfar, et al. 2013, WHO, 2000;Guideline and Procedure Manual, 2012, IDAI, 2013: Guidelines, Mastitis And Breastfeeding, 2015: Katari Kamal, et al, 2012: The Women, 2012).Researchers thought that in the positive

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Qanun Medika vol.no.|bulan tahun group, with a single therapy Amoxicilin antibiotics were better, (can increase levels of cytokines IL-10) compared to just using aqua pro injection.In the treatment group induced by Staphylococcus aureus bacteria (0.2 mlx108 ml / CFU), antibiotics were given Amoxicilin at a dose of 9 mg / ml / 250gramBB + pagoda leaf extract at a dose of 50 mg / KgBB mice for 5 days).The result is clear that there are differences between groups before, during and after being given Amoxicilin and pagoda leaves.It was shown that the group given Amoxicilin + pagoda leaf extract had increased levels of IL-10 cytokines 2-fold compared to the positive control group and negative controls.The results of the histopathology test in the treatment group seen inflammatory cells.This is in line with the results of research where Pagoda leaves contain active compounds such as tannins and flavonoids.Compounds in flavonoids can inhibit the production of proinflammatory cytokines, such as tumornecrosis factor (TNF-α), inflammatory protein macrophages-1, and activate and increase interleukin-10 (IL-10), where IL-10 is activated by monocytes.Flavonoids are polyphenolic compounds that occur ubiquitously on plants.

CONCLUSION
Based on the description above, researchers assume that pagoda leaf extract can be used as a complementary therapy in the treatment of mastitis because it can increase levels of cytokines Interleukin-10 which acts as an antiinflammatory so that it can suppress the inflammatory response / infection that occurs when exposed to microorganisms.

(
Figure I) Microscopic picture of the breast of the normal control group showed that the lactiferous duct was coated with normal epithelial cells and surrounded by connective tissue and blood vessels (Figure II) Microscopic images of the mice of the negative control group, namely the group induced by Staphylococcus aureus bacteria without treatment, it was shown that there were inflammatory (± 100) Polymorphonuclear (PMN) cells around the connective tissue which were not found in the normal control group.It appears that thickening of the epithelial cell layer surrounding the lactiferous duct (Figure III) Microscopic picture of the breast of the mouse in the positive control group is the group induced by Staphylococcus aureus and given 9.6ml / 250grBB of amoxilcillin antibiotics per day orally for 5 (five) days showing the cell -inflammatory cells (± 70) Polymorphonuclear (PMN) around the connective tissue and surrounding epithelial cells and reduced lactiferous ducts (Figure IV) Microscopic images in the mice breast of the treatment control group ie the group induced by Staphylococcus aureus and halaman induced by Staphylococcus aureus bacteria (0.2 mlx108 ml / CFU), antibiotics were given Amoxicilin at a dose of 9 mg / ml / 250gramBB + pagoda leaf extract at a dose of 50 mg / KgBB mice for 5 days).The result is clear that there are differences between groups before, during and after being given Amoxicilin and pagoda leaves.It was shown that the group given Amoxicilin + pagoda leaf extract had increased levels of IL-10 cytokines 2-fold compared to the positive control group and negative controls.The results of the histopathology test in the treatment group seen inflammatory cells.This is in line with the results of research where Pagoda leaves contain active compounds such as tannins and flavonoids.Compounds in flavonoids can inhibit the production of proinflammatory cytokines, such as tumornecrosis factor (TNF-α), inflammatory protein macrophages-1, and activate and increase interleukin-10 (IL-10), where IL-10 is activated by monocytes.Flavonoids are polyphenolic compounds that occur ubiquitously on plants.They are found to antiplatelet and anti-inflammatory activitieshave anti-inflammatory activity in both the proliferative and exudative phases of inflammation.(RatheeRermender 2009:  Hafiz Ihsanul, et al 2016).Shrivastava, et  al, 2007:Kumar;2000 & John M. Leech,  et.al, 2017 : (Shrivastava, N Patel, et al.T.2007.Musa Weni, Et al, 2009: Hoensch  HP et al.2018)
homeostasis.Interleukin-10 levels as antiinflammatory cytokines will decrease if there is inflammation in the body(Couper  N Kevin, et al 2008; Rayitno A, et al,  2014; Garcia YF, et al, 2011; Iyer  Subramanian S, et al, 2012; Kumar Ashok,  et al, 2000; AmirH.Lisa, et al, 2014) Histopathology test done at the hospital University of Hasanuddin Makassar.The tissue taken for the sample is breast tissue in all groups.This research was approved and issued by the Ethical Commitment of the University of Hasanuddin Makassar on February 5, 2018 with No. 116 / H4.8.4.5.31 / PP36-KOMETIK / 2018.Data is processed and analyzed using computer assistance, to see the effect of

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Biopharmaca laboratory for drying plants, Pharmacy Laboratory of State Islamic University (UIN) Makassar to extract and phytochemical testing, animal laboratory UNHAS for the process of rats adaptation to the end of the treatment given.Histopathology test done at the hospital University of Hasanuddin Makassar.The tissue taken for the sample is breast tissue in all groups.This research was approved and issued by the Ethical Commitment of the University of Hasanuddin Makassar on February 5, 2018 with No. 116 / H4.8.4.5.31 / PP36-KOMETIK / 2018.Data is processed and analyzed using computer assistance, to see the effect of Histopathology test done at the hospital University of Hasanuddin Makassar.The tissue taken for the sample is halaman examination for Enzyme Linked Immunosorbent Assay (ELISA) and culture of Staphylococcus aureus bacteria,is carried out by intramuscular technique in the breast part precisely in the lactiferous duct in rats in all groups (Negative, positive and treatment) after the induction of bacteria is then observed ±24 hours later to see an infection reaction in the rat breast area (There are signs of infection in the breast)The research data collection instrument was carried out by method Enzyme Linked Immunosorbent Assay (ELISA) to measure IL-10 levels.halamanRESULTS

Table 1 .
Phytochemical test results of the compound of Leaf Pagoda (Clorodendum Paniculatum L).

Table 2 .
The mean body weight of mice in each group

Table 3 :
Average differences in IL-10 levels in each female rat group Sprague Dawley strain before, after induction of Staphylococcus aureus bacteria and after treatment.

Table 1 .
Phytochemical test results of the compound of Leaf Pagoda (Clorodendum Paniculatum L).
Picture 1: Trend of IL-10 levels in each group of female rats with Sprague Dawly strain before, after induced Staphylococcus.Aureus and after treatment..Qanun Medika vol.no.|bulan tahunhalaman RESULTS

Table 4 :
Analysis of differences in IL-10 levels before, after induced Staphylococcus aureus bacteria and after treatment in each group Post hoc analysis before and after induced Staphylococcus aureus bacteria obtained a value of ρ> 0.05 between each group.It showed no difference in levels of IL-10 cytokines, both before and after induction of ± 24 hours of Staphylococcus aureus bacteria in all groups.Whereas after being given treatment, the value of p <0.05 was obtained between all groups.This shows that there are differences in IL-10 levels after treatment between all groups.

Qanun Medika vol. no. |bulan tahun halamanTable 5 :
Analysis Of Differences In Il-10 Levels Between Groups Of Female Sprague Dawley Strain Rats Before, After Induced By Staphylococcus aureus Bacteria And After Treatment.

Table 6 :
Analysis of Velocity in the positive control group and treatment groupShowing the results of velocity test in the positive control group obtained 133.4% antibiotics can increase levels of IL-10 cytokines, whereas in the treatment group obtained 271.5% antibiotics and pagoda leaf extract can increase levels of IL-10 cytokines, with the difference between positive control groups and the treatment group was 138%.This shows that pagoda leaf extract can increase the levels of IL-10 cytokines by around 138%.

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T.2007.Musa Weni, Et al, 2009: Hoensch  HP et al.2018)CONCLUSIONBased on the description above, researchers assume that pagoda leaf extract can be used as a complementary therapy in the treatment of mastitis because it can increase levels of cytokines Interleukin-10 which acts as an antiinflammatory so that it can suppress the inflammatory response / infection that occurs when exposed to microorganisms.lipoxygenase, cycloxygenase.Flavonoids have anti-inflammatory activity in both the proliferative and exudative phases of inflammation.(Rathee Rermender 2009: Hafiz Ihsanul, et al 2016).Shrivastava, et al, 2007:Kumar; 2000 & John M. Leech, et.al, 2017 : (Shrivastava, N Patel, et al.